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Contributors 


WILLIAM E. ADAMS, M.D. 

PuiynioiuJ Professor of Surgery^ University 
of Chicay^o School of Medicine; Attending 
Surgeon, Albert Merritt Billings Hospital, 
(jhkago. 

JOHN ADRIAN!, M.D. 

Professor of Surgery, School of Medicine, 
Tiilane Ihiiversity; Clinical Professor of 
Surgery and Pharmacology, School of Medi- 
cine, Louisiana State University; Director, 
Departnieni of Anesthesiology, Charity Hos- 
pital, New Orleans, 

RUFUS H. ALLDREDGE, M.D. . 
Associate Clinical Professor of Orthopedic 
Surgery, Tidane University; Chief of Or- 
ihopedic Surgery, Tonro Infirmary and 
U.S. Veterans Hospital, New Orleans. 

HARVEY S. ALLEN, M.D. 

Late Professor of Surgery, Northwestern 
University; Attending Surgeon, Passavant 
Memorial Hospital, Chicago. 

WILLIAM A. ALTEMEIER, M.D. 

Professor of Surgery and Chairman of the 
Department, University of Cincinnati and 
the Cincinnati General Hospital, Cincin- 
nail 

ELETGI lER AUSTIN, M.D. 

Assovkue in Otolaryngology, Northwestern 
University; Attending Surgeon, Passavant 
Memorial Hospital, Chicago, 

SAM W. BANKS, M.D. 

Associate Professor of Orthopedic Surgery, 
Northwestern University; Attending Or'- 
thopedic Surgeon, Wesley Memorial Eos-’ 
pUal, Chicago, 


KNOWLTON E. BARBER, M.D. 

Assistant Professor of Urology, Northwest- 
ern University; Attending Surgeon, Passa- 
vant Memorial Hospital, Chicago. 

CLIFFORD J. BARBORKA, M.D. 

Associate Professor of Medicine, Nortlnvest- 
ern University; Attending Physician, Pas- 
savant Memorial Hospital, Chicago. 

JOHN L BELL, M.D. 

Associate in Surgery, Northwestern Uni- 
versity; Attending Surgeon, Passavant Me- 
morial Hospital, Chicago, 

BRIAN BLADES, M.D, 

Professor of Stirgery, The George Washing- 
ton University School of Medicine; Chief 
of Surgery, The George Washington Uni- 
versity Hospital, Washington, D.C, 

ARTHUR H. BLAKEMORE, M.D. 

Associate Professor of Clinical Surgery, Co- 
Imnbia University; Attending Surgeon, 
Presbyterian Hospital, New York. 

JAMES BARRETT BROWN, M.D. 

Professor of Clinical Surgery, Washington 
Ihiiversity School of Medicine; Associate 
Surgeon, Barnes Hospital, St. Louis. 

JOHN C. BURCH, M.D. 

Professor of Gynecology, Vanderbilt Uni- 
versity School of Medicine; Gynecologist-m- 
Chief, Vanderbilt University Hospital, 
Nashville. 

WALTER W. CARROLL, M.D. 

Associate Professor of Surgery, Northwest- 
ern University; Attending Surgeon, Pas- 
savant Metnorkl Hospital, Chicago. 


Page iii 



IV 


Contributors 


ROBERT L. CHALFANT, M.D. 

Instructor in Obstetrics and Gynecology, 
Vanderbilt University School of Medicine; 
Attending Gynecologist, Vcniderhilt Uni- 
versity Hospital, Nashville, 

EDWARD D. CHURCHILL, M.D. 

John Homans Professor of Surgery, Harvard 
Medical School; Chief of the General Sur- 
gical Sendees, Massachnsetts General Hos- 
pital, Boston. 

PAUL C. COLONNA, M.D. 

Professor of Orthopedic Surgery, University 
of Pennsylvania; Chief of the Orthopedic 
Department, University of Pennsylvania 
Hospital, Philadelphia. 

MURRAY M. COPELAND, M.D. 

Professor of Oncology, Georgetown Uni- 
versity Medical School; Director of the De- 
partment of Oncology, Georgetown Uni- 
versity Medical Center, Washington, D.C. 

GEORGE CRILE, Ja., M.D. 

Staff Member, Department of General Sur- 
gery, Cleveland Clinic, Cleveland. 

LOYAL DAVIS, M.D. 

Professor of Surgery and Chairman of the 
Department, North western University; At- 
tending Surgeon, Passavemt Memorial Hos- 
pital, Chicago. 

ROBERT E. DESAUTELS, M.D. 

Junior Associate in Surgery (Urology^ 
Harvard Medical School; Junior Associate 
in Surgery, Peter Bent Brigham Hospital 
Boston. 

JOHN M. DORSEY, M.D. 

Professor of Surgery, Northwestern Uni- 
versity; Chairman, Department of Surgery, 
Evanston Hospital, Evanston. 

JAMES E. ECKENHOFF, M.D. 

Professor of Anesthesiology, University of 
Pennsylvania; Anesthesiologist, University 
Hospital, Philadelphia. 


MINOT P. F’RVL.IL All). 

Assisiaiit fh'ojcssor oj ClhiiccI S'n/irrv 
W'hishingloii Uiiivcrdiiy SchonI rp Mnh 
cine; Assistant Siirgcnn, Ihifiics Hf.i'^piial 

St. Louis. 

CHARLES F'. CiNCIlK k I I IF M.D, 
Professor of Pifiholog] , Georgeiown Uni 
versity Medical Sehool; Diri'ctor (g I almni 
lories, Georgvtoivn Unirerdtv Medical i 'en 
ter, \'\'(ishingt(fic !).('. 

FBANK GLLNN, M.j). 

Lewis Aiterl)iiry Sthusf/n Projessar f>f Sur 
gery, Gorucll University Medieid Golh'vp; 
Siirgeou-iu Chief, Hie New Link Uosjaial, 
New York. 

ELISHA S. (TJRDjlAN, M.D. 

Professor of Neurosurgery, Wayne (/;;/• 
versity College of Medicine; Chief, Wayne 
University Neurosurgical Serviee, Grac(> 
Hospital, Detroit. 

OWEN GWAFllMl'V, M.D. 

Assistant Professor of Surgery, 'Lite George 
Washington University Schofd of Miuli 
cine; Associate in Surgery, 'the George 
Washington University Hosjntal Washing 
ion, D.C. 

GLORC^E A. HALLI'AlllTT, M.D. 

Assistant ih'ofessar of Idiysiology and Sur 
gery, I he Mayo Iviindaiion, Graduate 
School of the University of Minnesota; Sur 
geon, Mayo Clinic, P(Kdwster. 

J. HARTWELL HARRISON, Ml). 

Clinical Professor of Gcnitodlrhiary Sur- 
gery, Harvard Medical School; Urolagic 
Surgeon, Peter Rent Brigham Hospital, 
Boston. 

PAUL R. HAWLEY, MD. 

The Director, American College of Sur 
geons, Chicago. 

CHARLES A. HUFNAGEL, Ml), 

Associate Professor of Surgery, Georgetown 
University Mediad Center^, Wmhingtoih 



K^unii tumors 


V 


EDWARD S. JUDD, Jiu M.D. 

Associate Projcssor of Surgery^ The Mayo 
I'oii/ulal/o;/, Cnidmtc School of the Uni- 
versity of Minnesota; Surgeon, Mayo Clinic^ 
Rochester, 

ROBERT 11. KENNEDY, M.D. 

honnerly Professor of Clinical Siirp^ery, 
New York University Post-Cradtinte Medi- 
cal School; Surreal Director, Beehiian- 
Doivntown Hospital, New York. 

THOMAS II. LANMAN, M.D. 

Clinical Professor of Stiroery, Harvard 
Medical School, Poston. 

I l/\HOLD LAUEMAN, M.D. 

Associate Professor of Surgery, Northwest- 
ern University: Attending Stwgeon, Passa- 
vant Memorial Hospital, Chicago. 

J1()R/\CE T. LAVELY, Jr., M.D. 

Instructor in Gynecology, Vanderbilt Uni- 
versity School of Medicine; Assistant Gyne- 
cologlst, Vanderbilt University Hospital, 
Nashville, 

GEOPCR V. LbROY, M.D. 

Professor of Medicine and Associate Dean, 
llie Division of Biological Sciences, Uni- 
versity of Chicago, Chicago. 

PHILIP LE'.WIN, M.D. 

lAofcssor of Orthopedic Surgery, Emeritus, 
Northwestern University; Senior Attending 
Orthopedic Surgeon, Michael Reese Hos- 
pital, Chicago. 

ROfRilVl' B. IJiWIS, M.D. 

Colonel, United States Air Force Medical 
Corps. 

MANLIITR LICHTENSTEIN, M.D. 
Assaciate Professor of Surgery, Northwest^ 
cm University; Attending Surgeon, Nor- 
wegian'' American Hospital and Cook 
County Hospital, Chicago. 


FREDERICK A. LLOYD, M.D. 

Associate Professor of Urology, Northwest- 
ern University; Attending Surgeon, Pas- 
saimiit Memorial Hospital, Chicago. 


B. R LOUNSBURY, M.D. 

Assistant Professor of Surgery, Northwest- 
ern University; Attending Surgeon, Passa- 
vant Memorial Hospital, Chicago. 


IAN MACDONALD, M.D. 

Associate Professor of Surgery, University 
of Southern California School of Medicine; 
Senior Attending Surgeon, Tumor Sur- 
gery, Los Angeles County General Hospital, 
Los Angeles. 

SAMUEL F. MARSHALL, M.D. 

Surgeon, The Lahev Clinic and The New 
England Deaconess Hospital, Boston. 

MICHAEL L. MASON, M.D. 

Professor of Surgery, Northwestern Uni- 
versity; Attending Surgeon, Passavant Me- 
morial Hospital, Chicago. 


DONALD D. MATSON, M.D. 

Associate Clinical Professor of Surgery, 
Harvard Medical School; Neurosurgeon, 
Children's Medical Center, Boston. 


FRANCIS M. McKEEVER, M.D. 

Professor of Surgery (Orthopedic^ Uni- 
versity of Southern California School of 
Medicine; Senior Orthopedic Sitrgeon, Los 
Angeles County General Hospital and 
Childrens Hospital, Los Angeles. 


CHESTER B. MoVAY, M.D. 

Clinical Professor of Surgery and Associate 
Professor of Anatomy, The UnNersiiy of 
South Dakota School of Medical Sciences; 
S^irgeon, Yankton Clinic and Sacred Heart 
Hospital, Yankton, S.D. 



VI 


Contributors 


FRANK L. MELENEY, M.D. 

Professor E1lleTit^Ls of Clinical Surgery, Co- 
hiiubia University; Formerly Attending Sur- 
geon, Presbyterian Hospital, New York. 

FRANCIS D. MOORE, M.D. 

Mosely Professor of Surgery, Harvard Medi- 
cal School; Surgeon-in-Chief, Peter Bent 
Brigham Hospital, Boston. 

ROBERT M. MOORE, M.D. 

Professor of Stirgery and Chairman of the 
Department, University of Texas School of 
Medicine; Director of Surgical Services, 
Ujii versify of Texas Hospitals, Galveston. 

REED M. NESBIT, M.D. 

Professor of Surgery, University of Michi- 
gan Medical School; Chief of Urological 
Service, University Hospital, Ann Arbor. 

J. PEERMAN NESSELROD, M.D. 

Assistant Professor of Surgery, Northwest- 
ern University; Attending Surgeon, Evans- 
ton Hospital, Evanston. 

LOUIS B. NEWMAN, M.D. 

Associate Professor of Physical Medicine,' 
Northwestern University; Chief of Physical 
Medicine and Rehabilitation Service, Vet- 
erans Administration Research Hospital, 
Chicago. 

VINCENT J. O’CONOR, M.D. 

Professor of Urology and Chairman of the 
Department, Northwestern University; At- 
tending Urological Surgeon, Wesley Me- 
morial Hospital, Chicago. 

LEWIS J. POLLOCK, M.D. 

Emeritus Professor and Chairman of De- 
partments of Nervous and Mental Dis- 
eases, Northwestern University; Attending 
Physician, Passavant Memorial Hospital, 
Chicago. 

GERALD H. PRATT, M.D. 

Associate Clinical Professor of Surgery, 
New Yor'k University College of Medicine; 
Attending Surgeon, St Vincent's Hospital, 
New York 


JAMES T. PRIESTLEY, M.D. 

Professor of Surgery, The Muyo I’oundu 
tion, Graduate School, University of Min 
nesota; Surgeon, Mayo Clinic, Piochcsler. 

F. JOHNSON PUTNEY, M.D. 

Associate Professor of Ixiryngology and. 
Bronchoesophagology, Jefferson Medical 
College; Chief Clinical Assistant, Pron 
choscopy and Laryngology, Jefferson Mali 
cal College f lospitcil, PhiUidelphia. 

ISIDOR S. RAVDIN, M.D. 

John Rhea Barton Professor oj Surgery, 
School of Medicine, University of Penn 
sylvania; Surgeon-in -Chief , University Hos- 
pital, Philadelphia. 

BRONSON S. RAY, M.D. 

Professor of Clinical Surgery, (hirnell Uni 
varsity Medical College; Attending Sur 
geon, New York Hospital, New York. 

LEANDER W. RIB/\, M.D. 

Assistant Professor of Urology, Northwest 
ern University; Attending Surgeon, ihtssa 
i H'l nt Mem o ria III os pi tal, Chicago. 

LhROY a. SCIIALL, M.D. 

Waller Augustus LeCompte Professor of 
Otology and Professor of I uryngolijgr, liar 
vard Medical School: Chief, Department of 
Otolaryngology, Massachusetts Lye and P’ar 
Infirmary, Boston. 

ROBERT W. SCHNEIDER, M.D. 

Staff Member, Department of Lndocrin 
ology, Cleveland Clinic, Cleveland. 

HARRIS B. SHUMACKER, ja., Mi). 
Professor of Svtrgery and Chairman of Df 
partment, Indiana University School of 
Medicine, Indianapolis. 

HAROLD A. SOFIELD, Mi). 

Professor of Orthopedic Surgery, North- 
western University; Chief Surgeon, ShrlW' 
ers Hospital for Crippled Children, Chi- 
cago. 



Contributors 


vii 


JAMES K. STACK, M.D. 

Associate Professor of Orthopedic Surgery, 
NortJnaestern University; Attending Ortho- 
pedic Stirgeon, Passavant Memorial Hos- 
pital, Chicago. 

RICHARD W. STEENBURG, M.D. 

Harvey Cushing Fellow and Teaching Fel- 
low in Anatomy, Harvard Medical School; 
Senior Assistant Resident in Surgery, Peter 
Bent Brigham Flospital, Boston. 

JEAN M. STEVENSON, M.D. 

Associate Professor of Surgery, Unwersity 
of Cincinnati College of Medicine; Attend- 
ing Surgeon, Cincinnati General Hospital, 
Cincinnati. 

RICHARD H. SWEET, M.D. 

Associate Clinical Professor of Surgery, 
Harvard Medical School; Visiting Surgeon, 
Massachusetts General Hospital, Boston. 

E. CLINTON TEXTER, M.D. 

As.sociate in Medicine, Northwestern Uni- 
versity; Attending Physician, Passavant Me- 
morial Hospital, Chicago. 

DERRICK T. VAIL, M.D. 

Professor of Ophthalmology and Chairman 
of Department, Northwestern University; 
Attending Ophthalmologist, Passavant Me- 
morial Hospital, Chicago. 

RICI [ARD L. VARCO, M.D. 

Profe.s.sor of Surgery, The Medical School, 
University of Minnesota; Attending Sur- 
geon, University of Minnesota Hospital, 
Minneapolis. 

THEODORE E. WALSH, M.D. 

Professor of Otolaryngology and Chairman 
of the Department, Washington University 
School of M.edicine, St. Louis. 

WALTMAN WALTERS, M.D. 

Professor of Surgery, The Mayo Founda- 
tion, Graduate School of the University of 
Minnesota; Surgeon, Mayo Clinic, Roches- 
ter. 


JOHN M. WAUGH, M.D. 

Professor of S7trgery, The Mayo Founda- 
tion, Graduate School of the University of 
Minnesota; Surgeon, Mayo Clinic, Roches- 
ter. 

JOHN E. WEBSTER, M.D. 

Assistant Professor of N eurological Surgery, 
Wayne University College of Medicine; As- 
sociate Neurosurgeon, Grace Hospital, De- 
troit. 

CLAUDE E. WELCH, M.D. 

Clinical Associate in Surgery, Harvard 
Medical School; Visiting Surgeon, Massa- 
chusetts General Hospital, Boston. 

FRANCIS E. WEST, M.D. 

Chief, Orthopedic Section, San Diego 
County Hospital, San Diego. 

ALLEN 0. WHIPPLE, M.D. 

Valentine Mott Professor of Surgery, 
Emeritus, Columbia University, New York. 

JAMES C. WHITE, M.D. 

Professor of Surgery, Harvard University; 
Visiting Neurosurgeon, Massachusetts Gen- 
eral Hospital, Boston. 

ROGER D. WILLIAMS, M.D. 

Assistant Professor of Surgery, The Ohio 
State University School of Medicine; At- 
tending Surgeon, Ohio State University 
Health Center, Colmnhus. 

JOHN C. WILSON, Jr., M.D. 

Instructor, Department of Orthopedic Sur- 
gery, University of Southern California 
School of Medicine; Attending Orthopedic 
Surgeon, Los Angeles County General Hos- 
pital, Los Angeles. 

BERNARD ZIMMERMANN, M.D. 

Assistant Professor, Department of Surgery, 
The Medical School, University of Minne- 
sota; Attending Surgeon, University of Min- 
nesota General Hospital, Minneapolis. 

ROBERT M. ZOLLINGER, M.D, 

Professor of Surgery and Chairman of the 
Department, The Ohio State University 
School of Medicine; Surgeon-in-Chief, 
Ohio State University Health Center, Co- 

lumhus 




Preface 


Ilu’ (list c'diiitin ()1 Christophers Textbook 
{if Suri'i'n iippearetl twenty years ago. Since 
then ;ui\ aneemeiUs in the principles of siir- 
gcry, tiu' exltaision ol the hounds of surgical 
proeediirt's and the contributions of the basic 
scieiu'cs to surgicJii therapy have been out of 
tht' ('oiiiinon. 

Ilu‘ total sum ol these ellorts has made it 
iinpossihle lor any one indi\'idual to be expert 
in kno\vledgt‘ or perlorniance in all of the 
lields ol surgical endea\'or. In fact, the acquisi- 
tion ol lacts has been so rapid and far-reaching 
that inon now devote their professional lives to 
stipnents of tht‘ (ic’ld of surgery. 

1 h(‘ preceding editions of this textbook had 
as their purpose the presentation of autbori- 
tati\c articles by experienced teaehers on spe- 
eilic topies of interest in surgery. The success 
of ilu' hook among medical students and sur- 
gtains in practice through the years has been 
ph(uu)men;d, However, the manifold additions 
to surgical knowledge now make it necessary 
to ha\ e volumes of text devoted to one particu- 
lar spi'cialtv of surgical practice, if there is to be 
an eiK'ydopedie coverage of the subject. 

It is impossible to teach the medical student, 
in the redative short time devoted to the presen- 
tation of surgery in the medical school curricu- 
lum, all of the knowledge he must have to 
become a surgeon. It would appear to be 
sounder pedagogically to place before the stu- 
(kaU an intcre.stingly ttjld story of the facts and 
principles which should form the basis for his 
self education in surgery which must continue 
throughout his professional life. Every surgeon 
iiuist add his own educational scaffolding as he 
progresses through his surgical experiences. 


Each contributor to this edition has had the 
aim to present his subject in such a way that he 
will stimulate the young and older .students of 
surgery alike to read further, to think through 
the problems presented by each of their pa- 
tients, and to ascertain by themselves the ana- 
tomic, physiologic, bacteriologic, pathologic, 
biochcmic and pharmacologic factors involved. 
Surgery is the art of the application of the 
basic medical sciences and each individual en- 
gaged in its complexities of judgment, responsi- 
bility and decision must continue to educate 
and improve himself without thought of an 
end point. 

Each contributor has written in his own style 
of teaching and each one is authoritative in his 
field; each hopes that he will create in the 
reader a desire to learn more about the sub- 
ject presented. Reading references have been 
provided to encourage the inquisitive and 
imaginative to seek further. 

The education of a surgeon involves many 
fields of learning and the first and the last chap- 
ters suggest what other disciplines may go into 
the making of a surgeon. The appreciation of 
tradition, the only way by which wisdom may 
be passed on from generation to generation; 
the realization that integrity, ideals, judgment, 
decision, action and the practice of the Golden 
Rule must often be upheld or exercised in- 
stantaneously by the surgeon; these, among 
many other requisites, demand that the sur- 
geon be completely prepared to assume re- 
sponsibilities not required of other practitioners 
of the art of medicine. 

Loval Davis 


Page k 




Contents 


Chapter 1 

HISTORY OF SURGERY 1 

ALLEN O. WHIPPLE, M.D. 

Chapter 2 

PHYSIOLOGY OF WOUND HEALING j . N 

WILLIAM A. ALTEMEIER, M.D., AND JEAN M. STEVENSON, M.D. ' 

Ch after 3 

SURGICAL BACTERIOLOGY, CHEMOTHERAPY AND ANTI- 
BIOTIC THERAPY : 42 

FRANK L, MELENEV, M.D. 

Chapter 4 

SHOCK 

ISIDOR S. RAVDIN, M.D., AND JAMES E. ECKENHOFF, M,D. 

Chapter 5 ^ 

PRINCIPLES OF PRE- AND POSTOPERATIVE CARE 109 

Preoperative^ Operative and Postoperative Care \J109 ' 

RICHARD L. VARCO, M.D. 

'v ^ 

Management of Fluid and Electrolytes in Surgical Practice 132 

BERNARD ZIMMERMANN, M.D. 

Chapter 6 

ENDOCRINOLOGY AND METABOLISM IN SURGICAL CARE . 143 

FRANCIS D. MOORE, M.D., AND RICHARD W. STEENBURG, M.D. 

Chapter 7 

ANESTHESIOLOGY Ad 

\ 

JOHN ADRIANI, M.D. 

Chapter 8 

BASIC PRINCIPLES OF TECHNIQUE IN SURGICAL CARE .... 186 

B. F. LOUNSBUEY, M.D. 

Page xi 



Contents 


Chapter 9 

THE PRINCIPLES OF THE SURGICAL CARE TO 1HI': SOM' 
TISSUES . 202 

HARVEY S. ALLEN, M.O. 


Chapter lO 

THERMAL AND IRRADIATION INJURIES 2 If) 

Burns . 210 

HARVEY S. ALLEN, M.D. 

Local Cold Injury 22 S 

ROBERT B, LEWIS, M.D. 

Irradiation Injuries 201 

JOHN L. BELL, M.D. 

Nuclear Radiation Injuries 22 S 

GEORGE V, LEROY, M.D. 


Chapter 11 

TEIE HEAD 240 

The Scalp 240 

LOYAL DAVIS, M.D. 

The Eyes 242 

DERRICK r, VAIL, M.D. 

The Nose, Nasal Accessory Sinuses and the Pharynx ............ 249 

FLETCHER AHSTIN, M.D. 

Tumors of the Nose, Nasal Sinuses and Nasopharynx 262 

LEROY A. SCHALL, M.D. 

The Ears ^ ^ ^ 26S 

THEODORE E. WALSH, M.d‘ 

The Mouth, Tongue, Jaws and Salivary Glands 274 


JAMES BARRETT BROWN, M.D., AND MINOl^ F. FRYER, M.D. 

Chapter 12 

THE NECK 3} 3 

Developmental Anomalies, Tumors, Infections and Wounds of the 

313 

WALTER W. CARROLL, M.D. 

Larynx and Trachea ' 

F. JOHNSON PHTNEY, M.D. 


Chapter 13 

THE THYROID AND PARATHYROID GLANDS 

GEORGE CRILE, JR., M.D., AND ROBERT W. SCHNEIDER, M.D. 


339 



Contents 


xiii 

Chapter 14 . 

THE BREASTS i’348 

***** 

IAN MACDONALD, M.D. 

Cha]iter 15 

11 IE MEDIASTINUM 389 


JOHN M. DORSEY, M.D. 

CUapler 16 

11 li: 11 lORAClC WALL, PLEURA AND LUNGS 

11 le llioracic Wall and Pleura 

WILLIAM E. ADAMS, M.D. 

Dheases of the Lungs and Bronchi 

BRIAN BLADES, M.D., AND OWEN GWATHMEY, M.D 

Tuiuors of the Lungs and Bronchi 

EDWARD D. CHURCHILL, M.D. 


Chapter 17 

THE HEART AND PERICARDIUM 437 

CHARLES A. HUFNAGEL, M.D. 

Chapter 18 

T1 IE ABDOMINAL WALL AND PERITONEUM 474 

MANUEL E. LICHTENSTEIN, M.D. 


Chapter 19 

HERNIA 

CHESTER B. MCVAY, M.D 


Chapter 20 

THE ALIMENTARY CANAL 556 

Congenital Malformations 556 

THOMAS H. LANMAN, M.D. 

The Esophagus 577 

RICHARD H. SWEET, M.D. 

The Stomach 5-— 

Peptic Ulcer and Benign Gastric Lesions 1 58^^ > 

CLIEEORD J. BARBOKKA, M.D., AND E. CLINTON TEXTER, JR*, 

M.D. 

//' ' ' •' ' ‘x. 

The Surgical Treatment of Peptic Ulcer .j 606 * 

WALTMAN WALTERS, M.D. V 



401 

401 

414 

430 



XIV 


Contents 


Tumors of the Stomach /)18 

SAMUEL F. MAESHALL, M.D. 

The Diiodenihn , jejunum, Ilenvi and Appendix 632 

JAMES T. PRIESTLEY, M.D., AND EDWARD S. JUDD, j IL, M.I). 

The Colon 634 

CLAUDE E. WELCH, M.D. 

The And Canal and Rectum 664 

J. PEERMAN NESSELROD, M.D. 

Intestinal Ohsiriiction \ 6(S4 

ROBERT M. MOORE, M.D. 


Chapter 21 

THE LIVER AND BILIARY SYSTEM 712 

Anatomy and Physiolopiy of the Liver ujul Biliary Syslem and Dis 

eases of the Gallhladder and Bile Ducts 712 

FRANK GLENN, M.D. 

Diseases of the Liver 740 

ARTHim I-I. BLAKEMORE, M.D. 


Chapter 22 

THE PANCREAS 

JOFIN M. WAUGH, M.D., AND GEORGE A. IIALLENHECK, M.D, 


7S6 


Chapter 23 

THE ADRENAL GLANDS 

J. HARTWELL HARRISON, M.D., AND ROBEIVr E. DESACnELS, M.IX 


775 


Chapter 24 

THE SPLEEN 

ROBERT M. ZOLLINGER, M.D., AND ROGER D. WILLIAMS, M.D. 


798 


Chapter 25 

THE URINARY SYSTEM 

Methods of Diagnosis 

REED M. NESBIT, M.D. 

Infections of the Urinary Tract . . , . 
VINCENT J. o'cONOR, M.D. 

Anomalies and Injuries 

KNOWLTON E. BARBER, M.D. 
Tumors and Calculi 

FREDERICK A. LLOYD, M.D, 


810 

810 

816 

831 




Contents 


Chapter 26 

THE MALE REPRODUCTIVE SYSTEM (878 

LEANDEK W. RIBA, M.D. 

Chapter 27 

THE FEMALE REPRODUCTIVE SYSTEM 897 


JOHN C. BURCH, M.D., HORACE T. LAVELY, JR., M.D., AND 
ROBERT L. CHALFANT, M.D. 


Chapter 28 

THE BONES AND JOINTS 953 

Considerations in the Treatment of Closed and Open Fractures .... f 953' • 

ROBERT H. KENNEDY, M.D. “ 

Pathology and Repair of Fractures 963 

PAUL C. COLONNA, M.D. 

Fractures and Dislocations ^72 

Fractures and Dislocations of the Upper Extremity and Spine . . 972 


SAM W. BANKS, M.D. 

Fractures and Dislocations of the Pelvis and the Lov/er Extremity d027 


HAROLD A. SOFIELD, M.D. 

Muscles, Ligaments and Bursae 1073 

JAMES K. STACK, M.D. 

Acute and Chronic Infections of the Bones and Joints 1084 

FRANCIS M. MCKEEVER, M.D., AND JOHN C. WILSON, JR., M.D. 

Tuberculosis of the Bones and Joints 1111 

FRANCIS E. WEST, M.D. 

Tumors of the Bones and Joints 1121 


MURRAY M. COPELAND, M.D., AND CHARLES F. GESCHICKTER, 
M.D. 


Chapter 29 

SURGERY OF THE FIAND 1146 

MICHAEL L. MASON, M.D. 

Chapter 30 

SURGERY OF THE FOOT 1229 

PHILIP LEWIN, M.D. 

Chapter 31 

AMPUTATIONS AND ARTIFICIAL LIMBS 1240 

RUFUS H. ALLDREDGE, M.D. 



XVI 


Contents 


Chapter 32 

PHYSICAL MEDICINE AND REHABILITATION 

LOUIS B. NEWMAN, M.D. 

^ Chapter 33 

THE VASCULAR SYSITM 

The Veins 

HAROLD LAUEMAN, M.D. 

The Arteries 

HARRIS B. SHUM ACKER, jlL, M.l) 

The Lymphalks 

GERALD H. PRA'f’T, M.D, 


Chapter 34 

THE NERVOUS SYSTEM I MR 

Neurosurgical Diap^nostic Procedures 

LOYAL DAVIS, M.D. 

Craniocerehral Injuries | M6 

ELISHA S. GURDJIAN, M.D., AND JOHN H. WEBS'O-U, M.D. 

The Cerebrum and Cerebellum 1374 

BRONSON S. RAY, M.D. 

The Spinal Cord !392 

LOYAL DAVIS, M.D. 

The Peripheral and Cranial Nerves 1 

LEWIS J. POLLOCK, M.D. 


The Autonomic Nervous System; The Neurasurpical Belief of Puiu 1415 

JAMES C. WHITE, M.D. 

Congenital Anomalies 1431 

DONALD D. MATSON, M.D. 

Chapter 35 

VhE qualifications of a surgeon 1442 

PAUL R. HAWLEY, M.D. 


!2S1 

1 2'),S 

1,U6 


INDEX 


1447 



Publisher’s Foreword 


The Saunders Company takes great pride in 
looking back over the long life and distin- 
guished service to medicine of the Textbook of 
Surgery edited by Frederick Christopher, M.D., 
Emeritus Professor' of Surgery at Northwestern 
University Medical School. It now takes equal 
pride in looking forward to the continuation of 
that text as an effective teaching instrument 
under the editorial direction of Loyal Davis, 
M.D,, Chairman of the Department of Surgery 
of Northwestern University Medical School. 

The essential purpose of the text and the 
essential means to its accomplishment were 
initiated by Dr. Christopher and are here car- 
ried onr in the Sixth Edition by Dr. Davis. In 
this new issue of the text Dr. Davis has given 
the separate contributors broader segments of 
surgery for discussion. This has resulted in a 
kinship of philosophy and identity of didactic 
purpose among the contributors which give the 
text much of the cohesiveness and force of a 
single-handed effort^ut the method^of present- 
ing separate subjects by separate authors re- 
mains the same and achieves the same effect of 
authority and comprehensiveness. 

One of the immediate accomplishments of 
the Editor has been preparation of the bio- 
graphical sketches which appear beneath the 
names of each of the contributors to this Text- 
book, save his own. This one, missing biography 
the publisher would like to' fill in here. 

Loyal Davis was bom in Galesburg, Illinois, 
and received his education at Knox College and 
Northwestern University. As a Fellow of the 
National Research Council, he received his sur- 
gical training under Allen B. Kanavel and spent 
a year as a voluntary assistant in neurological 


surgery at the Peter Bent Brigham Ffospital in 
Boston. He returned to Northwestern Uni- 
versity Medical School and assumed the Chair- 
manship of the Department of Surgery in 1932. 

During World War II, he was the senior con- 
sultant in neurological surgery to the Chief 
Surgeon of the European Theatre of Opera- 
tions from 1942 to 1944 and was one of the 
two surgeons from the United States who were 
members of the first surgical mission to Rus- 
sia. His contributions in surgery, neurological 
surgery, medical education and literature are 
numerous. He has been Editor of Surgery, 
Gynecology and Obstetrics since 1938. 

It may be imagined that the publishing prob- 
lems in processing so large a text by so many 
authors are difficult. In these problems Dr. 
Davis has shown toward his associates and his 
publisher unfailing helpfulness and decisive 
judgment. It is due to his untiring effort that 
publication of the book has been achieved in 
five months since receipt of the completed 
manuscript. 

Finally, the publisher would like to add a 
word of appreciation to the one indispensable; 
person in the long, mysterious, and complex! 
process of transforming thoughts to words and| 
words to printing. He is the contributor. It is oh 
his work and his authority that this book rests.! 
The text reflects his investigation, his clinical! 
insight, his experience, his skill, his conclusions.! 
This book through the contributor becomes a^ 
mirror of modern surgery, in which many act! 
together in a common cause and in which th^ 
knowledge of all is freely called upon. 

W. B. Saunders Company 



Publisher’s Foreword 


The Saunders Company takes great pride in 
looking back over the long life and distin- 
guished service to medicine of the Textbook of 
Surgery edited by Frederick Christopher, M,D., 
Emeritus Professor' of Surgery at Northwestern 
University Medical School. It now takes equal 
'^rride in looking forward to the continuation of 
that text as an effective teaching instrument 
under the editorial direction of Loyal Davis, 
M.D., Chaiiman of the Department of Surgery 
of Northwestern University Medical School. 

The essential purpose of the text and the 
essential means to its accomplishment were 
initiated by Dr. Christopher and are here car- 
ried oir in the Sixth Edition by Dr. Davis. In 
this new issue of the text Dr. Davis has given 
the separate contributors broader segments of 
surgery for discussion. This has resulted in a 
kinship of philosophy and identity of didactic 
purpose among the contributors which give the 
text much of the cohesiveness and force of a 
single-handed effort;^ut the method^of pre.sent- 
ing separate subjects by separate authors re- 
mains the same and achieves the same effect of 
authority and comprehensiveness. 

One of the immediate accomplishments of 
the Editor has been preparation of the bio- 
graphical sketches which appear beneath the 
names of each of the contributors to this Text- 
book, save his own. This one missing biography 
the publisher would like to 1111 in here. 

Loyal Davis was bom in Galesburg, Illinois, 
and received his education at Knox College and 
Northwestern University. As a Fellow of the 
National Research Council, he received his sur- 
gical training under Allen B. Kanavel and spent 
a year as a voluntary assistant in neurological 


surgery at the Peter Bent Brigham Hospital in 
Boston. He returned to Northwestern Uni- 
versity Medical School and assumed the Chair- 
manship of the Department of Surgery in 1932. 

During World War II, he was the senior con- 
sultant in neurological surgery to the Chief 
Surgeon of the European Theatre of Opera- 
tions from 1942 to 1944 and was one of the 
two surgeons from the United States who were 
members of the first surgical mission to Rus- 
sia. His contributions in surgery, neurological 
surgery, medical education and literature are 
numerous. He has been Editor of Surgery, 
Gynecology and Obstetrics since 1938. 

It may be imagined that the publishing prob- 
lems in processing so large a text by so many 
authors are difficult. In these problems Dr. 
Davis has shown toward his associates and his 
publisher unfailing helpfulness and decisive 
judgment, It is due to his untiring effort that 
publication of the book has been achieved in 
five months since receipt of the completed 
manuscript. ' 

Finally, the publisher would like to add a. 
word of appreciation to the one indispensable, 
person in the long, mysterious, and complex! 
process of transfonning thoughts to words and; 
words to printing. He is the contributor. It is onl 
his work and his authority that this book rests. 
The text reflects his investigation, his clinical 
insight, his experience, his skill, his conclusions.! 
This book through the contributor becomes ^ 
mirror of modem surgery, in which many act! 
together in a common cause and in which the 
knowledge of all is freely called upon. | 

W. B. Saunders Company ; 




1 


History of Surgery 

By ALLEN 0. WHIPPLE, M.D. 

Allen Oldfather Whipple received his edmation at Princeton and Columbia 
Universities. He has served the former with distinction as a Trustee and the latter 
as Valentine Mott Professor of Surgery. While Director of the Surgical Service at 
Columbia Presbyterian Hospital of New York he pioneered in the surgery of the 
pancreas and spleen and actively encouraged and secured an intimate cooperation 
between the surgeon and the bacteriologist. His scholarly attainments have made 
him a valuable consultant to foreign countries in medical education. His equanimity 
and kindly spirit have given him an enviable position in American surgery. 


Surgery has been defined as f That branch 
of Medical Science which treats of mechanical 
or operative measures for healing diseases, de- 
formities and injuries"; that is, surgery is a 
branch of medical science, it has to do with 
therapy carried out by the hands, its purpose 
is to heal 

Certainly surgery is the oldest branch of 
therapy. It began in prehistoric ages with 
primitive man, when in his struggle for exist- 
ence he was continually in conflict with the 
animals he hunted, or that were hunting him, 
as well as with his human enemies. Wounds, 
incised and lacerated, and hemorrhage from 
tliem, demanded immediate treatment by some 
member of his family, or later of his tribe, who 
had the courage and the knowledge to deal 
with bleeding gaping wounds, by such crude 
methods as pressure and the application of moss 
and cobwebs. The first surgeon may have been 
a frantic mother rescuing her wounded child 
from one of the carnivores. 

The history of surgery is a very long one. 
It is impossible, in one chapter, to give in any 
detail the evolution of the processes which have 
brought it to its high eminence today or to 
name all the surgeons through historic ages 
who have had to do with its evolution. For this 
only certain categories and problems 


that appear to he most important in the devel- 
opment of the art and science of surgery will 
be discussed, in the hope that the medical stu- 
dent and the busy practicing young surgeon 
will be stimulated to read, in more detail, the 
story of surgery, as given in the texts and 
literature of that subject. 

At the beginning it is important to appre- 
ciate that surgery has been, and still is, a more 
definite form of therapy than medicine, and the 
results, good or bad, are more convincing, Th^ 
lesions that required surgery in the early his- 
toric and prehistoric periods had a definite 
etiology and were not ascribed, as were so many 
medical complaints, to demonic and theurgic^ 
causes. Through the ages attempts to demear; 
surgery as a manual act, to be assigned to ig^ 
norant barbers and menials, have ultimately 
failed, because injury, wounds, profuse hem- 
orrhage and deformities could not be exorcisecj 
or cured by incantations or the administratioi^ 
of a noxious polypharmacon. i 

Because so many surgical procedures ar^ 
concerned with wounds, accidentally acquire!^ 
or made by the surgeon himself, the first 
category to be discussed is 
Wound Repair. This will be followed b|; 
Hemostasis, Anesthesia and Training of th| 
Surgeohr"""" 

i'. 


Page 1 


reason 



Limpter 1. History of Surgery 


WOUND CAME AND WOUND REPAIR 

From Antiquity into Nketeentii Century. 
The first authentic recoi'd we have on the care 
of wounds is from Egypt. The Edwin Smith 
Papyrus is considered to be a copy of one or 
more earlier ones written some 3000 years b.c. 
In this papyrus the treatment of wounds is 
mentioned. It consisted of holding the wound 
edges together with bandages to be obtained 
from the embalmers. In the fibers Papyrus, 
written about 1550 b.c., which was a com- 
pilation of texts of earlier periods, the treat- 
ment of wounds is recorded as consisting of 
maintaining apposition of wound edges by 
means of linen bandages soaked in myrrh and 
honey, to he removed after four days. 

Sumerian, Babylonian and Chinese medicine 
made no contribution to the subject. The Chi- 
nese used scarification and the actual cautery 
and cupping in their surgery. The two famous 
Hindu surgeons and physicians, Charaka and 
Susruta, of uncertain date, and their teachings, 
are described in the Charaka Samhita (second 
century? a.d.) and the Susruta Samhita (fifth 
century? a.d.). The latter describes some 121 
surgical instruments of various kinds. The use 
of the ligature was apparently unknown. Am- 
putations were done and hemorrhage was con- 
trolled by pressure, cautery and boiling oil. 

The first record dealing with the care of the 
wound by the Greeks is to he found in the 
homeric poems, the Iliad and the Odyssey. Ac- 
cording to Daremberg, some 141 wounds arc 
mentioned in these poems, for they had to do 
with warfare. The treatment of wounds caused 
by arrows, swords and spears consisted of the 
cemoval of the weapon, enlarging the wound 
by knife dissection if necessary, cleansing of 
the wound, and the application of astringent 
powders, compresses and bandages. 

; The temple of Asclepios at Cos was one of 
nany temples of Aesculapius, the Greek god of 
nedicine. It was in Cos that the great physi- 
dan, Hippocrates, was born in 460 b.c., and 
it was in the medical school of the temple of 
Asclepios that he studied. One of the books of 
he Corpus Hippocraticum believed to have 
)een written by him is entitled, ^'On Wounds 
ind Ulcers. In it he distinguishes primary 
mm secondary wound healing, and empba- 
Jzes the importance of cleansing the hands 
: ud the fingernails before operating, as well as 
:he advantages of pure or boiled water and 
jyine in the cleansing of wounds. It was his 
.freedom from superstition and mysticism, as 


well as his honest and ohjective obserxation 
symptoms and signs, that make i bppocnites t! 
first great jdivsician and surgeon in histnr\. 

With the record ol Hippocratic siirgciv an 
Hippocrates’ recognition of the ackantages ( 
primary wound healing began a hitter contia 
versy hctv\'cc'n those ach'oeating healing b\ lir^ 
intention and the protagonists of suppurati\ 
wound healing-one that continued for e('n 
turies, with the ad\’()eates ol laudable^ pus doini 
nating wound care most of the time unti 
Lister's cj)oelMnaking tliseo\eries. 

The lanious /Mexandrian School, loufulec 
in the third century h.c., contrihuted soiindK 
to anatomy because of the vivisections and au 
topsics which were penniuee! tlK'rc at that 
time. But the discoveries of I lerophiliis and 
firisLstratus in anatomy did not result in an\ 
great contribution to the problem of wound 
repair, or to the siil)se<[uent eontnn'crsy. 1 low 
ever, the surgery done at the AIt\\'aiKlrian 
wSchool was transmitted to the (irecn lloinan 
period. It was here that the ligature was first 
used, as will be meiitioned later. 

Crulcn (131-201 A.D.), the great figure in 
Roman rncdicine, was born in Ik'rgamon, Asia 
Minor, and spent his earlier \var.s of practice 
in that city, where he cared for tlic gladiators 
in the gymnasium. 1 le was thus a!)le to obseine 
Imsh extensive incised wounds, and found that 
if they were irrigated with wine and closed 
with linen sutures they healed promptly with- 
out the formation of pus, and that many <ir 
the gladiators were able to resume their oe 
cupations. Unfortunately for posterity, (kdeiEs 
early surgical experiences and interests were 
forgotten in his later polypharmacy. But in his 
original anatomic studies he empluisi/c<l the 
importance of knowing the site and si/e of 
anatomic structures in dealing with wounds 
‘If under such circumstances t)ne does not 
know the position of an important nerve or 
muscle, or of a large artery or v^ein, it can Itap 
pen that one helps the man to death, or some 
times mutilates him, instead of saving 
^ With the decline and Fall of the Rom uii lim 
pire and the rise of Christianity there took 
place a different attitude toward 'sickness ami 
death. The dissolute customs and low morals 
of this late Roman period drove many men 
into monastic orders, and the monasteries aiul 
churches became hostels for the sick and crip- 
pled. The monks took over the care of these 
people, using incantations and prayers in 
treating them, and reconciling them to the 



3 


Wound Care and Wound Repair 


belief that illness and disability were the in- 
evitable result of Gods will. 

The evolution of the wide separation of 
medicine and surgery that resulted from care 
of the sick by the monks and surgical treat- 
ment by the barbers attached to the monasteries 
to whose original duties of tonsuring the 
monks and clergy had been added the task 
of blood-letting, which eventually led to their 
role as surgeons, will he discussed in more de- 
tail in the section of this chapter dealing with 
training of the surgeon. 

During the Dark Ages of the fourth to the 
tenth century, medicine became more and more 
sterile because of its divorce from the definite 
disciplines of surgery; and because the latter 
was left in the hands of crude and uneducated 
barbers it in turn degenerated into a low es- 
tate, with fugitive lithotomists and hernio- 
tomists doing their hit-and-run operations 
under the worst of conditions. 

However, by the twelfth century the fact 
that wars continued and injuries occurred 
among the civilians made the services of the 
surgeon urgent and necessary, and in a few 
cases made the surgeon aware of the natural 
processes of wound healing. 

Hugo of Lucca (in the 1100 a.d. period) 
was an Italian army surgeon who believed in 
the simple nonsuppurative method of treating 
wounds. He taught this doctrine to his son 
and pupil Theodoric (1205-1296). In Theo- 
doric’s Treatise on Surgery he states Hugo's 
and his own views on the subject— 'Tor it is 
not necessary, as Roger and Roland have writ- 
ten, as many of their disciples teach, and as 
all modern surgeons profess, that pus should 
be generated in wounds. No error can be 
greater than this. Such a practice is indeed to 
hinder Nature, to prolong the disease, and to 
prevent the conglutination and consolidation 
of the wound.'' 

Hugo and Theodoric denounced the galenic 
tradition and its polypharmacy with suppura- 
tive measures in treating wounds and taught 
healing by first intention. For fresh wounds 
they rejected oils, salves and poultices and ad- 
vocated washing the wound with wine, re- 
moval of every foreign particle, and brought 
the wound surfaces together with a lint pad, 
soaked in wine, placed over the apposed edges. 
In old wounds they tried to obtain union by 
cleansing them and refreshing the wound 
margins. 


Two of the early French surgeons must be 
mentioned in connection with this subject, be- 
cause one supported primary wound healing, 
and the other did 'more than any one else to 
denounce it and delay its acceptance for the 
next 600 years. The first of these two surgeons, 
Henri de Mondeville was educated at Mont- 
pellier and later studied with Theodoric in 
Italy, where he obtained his ideas about treat- 
ing wounds which he strongly advocated. His 
writings were full of biting wit and withering 
sarcasm against galenic tradition. For this rea- 
son they were disple^ising to the Church and 
the cleric physicians, who were rigid in their 
acceptance of galenic lore, and for a long time 
were not published. Satirically, Flenri declared 
that God did not exhaust His creative powers 
in making Galen, and ridiculed the clerics who 
were supposed to know surgery by the Grace 
of God. He resented their jibes that surgery 
is merely a handicraft, and said that if the 
mind must inform the hand in its work, the 
hand likewise instructs the mind in its inter- 
pretation of the function of the hand. He 
was a keen observer of the rich and the poor. 
He stated, "Some of them [the rich] are as 
mean in their fat bellies as they are in their 
fat purses. If you have operated conscientiously 
on the rich for a proper fee, and on the poor 
for charity, you need not play the monk nor 
make pilgrimages for your soul.’' 

The method of treating wounds which 
Henri preached and practiced was as follows: 
"Wash the wound scrupulously from all foreign 
matter, use no probes, no tents except under 
special conditions; apply no oils or irritating 
matters; avoid the formation of pus, which is 
not a stage of healing but a complication^ 
Wounds dry much better before suppuration 
than after it. When your dressings have been 
carefully applied do not interfere with them 
for several days; keep the air out, for a wounc 
exposed to the air suppurates." (This certainly 
antedated Lister.) "With the new method yoi 
will have no stinks, shorter convalescence aiu 
clean thin scars. If treated on Thcodoric’s anc 
my instructions, every simple wound will hca 
without any notable quantity of pus. Man;^ 
surgeons know how to cause suppuration, fey 
how to heal a wound." He gives instruction' 
on how to operate— "Always put your need Id 
and thread in order before you operate, 
the thread not in a tangle, for blood will nd 
wait. Needles must be of various sizes, sharj 



Chapter L History of Surgery 


and clean, or they will infect the wound.” 

The second French surgeon, Guy de Chau- 
liac, is given special attention because of the 
baleful influence he had on subsequent gen- 
erations on the treatment of wounds. He lived 
in the fourteenth century, studied in Bologna, 
Montpellier and Paris and was aware of the 
teachings of Theodoric and of Henri de Mon- 
deville when he wrote his famous Text-book 
on Surgery. In his teachings in this book he 
was deaf to the message of primary wound 
healing, and adhered to the galenic tradition 
and advocated the suppurative treatment of 
wounds. So authoritative was his textbook that 
for the next 600 years laudable pus was con- 
sidered essential, even up to the time of Lister. 

In explanation of the belief in laudable pus 
it must be stated that in the wounds which 
were infected with virulent bacteria, the pa- 
tients died before suppuration developed, 
whereas patients with wounds infected with 
the less virulent pyogenic organisms survived 
rfter suppuration developed. So, pus was con- 
sidered laudable. 

The discovery of gunpowder and its use in 
warfare introduced a new type of wound which 
:aused endless controversy as to its nature. 
>ome claimed that these wounds were poisoned 
^ the gunpowder on the invading missiles. 
Jthers, in the minority, denied the poisonous 
heory. But the severe nature of these injuries 
)ccurring in the extremities, frequently asso- 
:iated with compound fractures, made amputa- 
ion mandatory. Such wounds, with or with- 
)ut amputation, were treated with boiling oil 
ind the actual cautery. 

Ambroise Pare, who will be discussed more 
ully later because of his restoration of the liga- 
ure in the handling of hemorrhage, was inter- 
|Sted in the subject of wound healing and 
hd much to improve it with his use of the 
igature, but still could not get away from the 
mployment of material which interfered with 
Matures healing processes, and had his pet 
fat saHe. He continued to follow much 
* Ouy de Chauliac^s teachings and induced 
u^uration m the treatment of his wounds 

The anatomic studies of Leonardo da Vinci 
nd of Vesalius, as well as the discovery of the 
jrcdaton of the blood by Harvey, broadened 
he helds of surgery extensively, but did not 
|store the teachings of Hugo, Theodoric and 
pem m their advocacy of primary wound 
l^mg. Even that greatest of English surgeons 
lefore Listers time, John Hunter, in his studies 


of inflammation, did not solve the problem of 
wound infection which prevailed in his dav 
and the first half of the nineteenth centur)'. 

During the latter part of the eighteenth cen- 
tury, because of the increased amount of sur- 
gery, the overcrowding of surgical wards, and 
especially because of the custom of ihc surgeons 
coming from the dissecting rooms to the ojierat- 
ing amphitheaters to perform their operations, 
without sanitary precautions, the incidence of 
infection in all forms— erysipelas, gas gangrene, 
septicemia, pyemia-was appalling (as high a.s 
80 per cent). In the maternity wards the in- 
cidence of puerperal sepsis was equally great. 

Before the discovery of ether and chloroform, 
which will be discussed in detail later, sjK'cd 
and sleight of hand work were the marks of a 
surgeon's competence. Chcselden is said to 
have performed a lithotomy in less than one 
minute and Liston a leg amputation in 
twenty-five seconds! But at this rate it is easily 
understood that antiseptic precautions could 
not he considered. Both from the patient’s and 
the surgeon’s standpoint an operation was to 
be performed in the shortest time possible. 

If wound infection could only be prevented 
what a blessing it would be to humanity! This 
idea must have occurred to every thoughtful 
surgeon in those dark days, as well as to the 
obstetrician. In fact, it was an obstetrician— 
Semmelweis (18l8-1865)-who first demon- 
strated the efficacy of antiseptic solution in 
cleansing the hands. While working in the 
Vienna General Hospital he made a keen ob- 
servation. In the maternity ward where the 
medical students, coming from the dissecting 
rooms, made vaginal examinations and took 
part in the deliveries, the mortality from puer- 
perd sepsis was four times higher than it was 
in the ward attended by midwives. When one 
of his associates cut his hand in the dissecting 
room, and died soon after of the symptoms of 
;^erperal sepsis, Semmelweis was convinced 
that sepsis was the result of uncleanliness. He 
inmoduced chlorinated water in the ward 
where the students worked, insisting that they 
w^h their hands thoroughly in this solution 
betore any examination or delivery. The inci- 
dence of puerperal sepsis dropped immediately 
to that of the ward attended hy the midwives. 
■Decause his discoveries were not recognized 
unbl years later, he brooded over it and? after 
publishmg his great work on the nature of 
puerperal sepsis in 1861, died insane. His 
name, however, will always be honored as 



5 


Wound Care and Wound Repair 


that of the man who first demonstrated the 
means of preventing wound infection. 

Dawn of Antiseptic and Aseptic Surgery. 
Two great men are responsible for smashing 
the specter of infection which had haunted 
the surgeon and physician for so many cen- 
turies. 

The world figure, Louis Pasteur (1822- 
1895), was a chemist, but he founded the sci- 
ence of bacteriology. By his epoch-making 
discoveries of the true nature of fermentation, 
especially as caused by lactic acid bacteria, he 
destroyed the doctrine of spontaneous genera- 
tion of organisms, which had been so strongly 
advocated by Liebig and other chemists. He 
proved that wine fermented because of the 
presence and growth of minute organisms, and 
that if these were eliminated by heat, fer- 
mentation did not take place. His original re- 
searches in anthrax and hydrophobia alone 
would have made him world famous. His basic 
studies in the true nature of putrefaction in 
animal matter by the action of bacteria set the 
pattern and initiated the work which was to 
follow. 

Joseph Lister (1827-1912) was a Quaker, 
and had the good fortune of having an emi- 
nent microscopist as a father and an under- 
standing and cooperative wife, the daughter 
of the famous Edinburgh surgeon, James 
Syme. After studying medicine at London 
University he decided to be a surgeon, and was 
accepted by Syme and became his very able 
house surgeon. 

At Syme s suggestion. Lister stood for, and 
was appointed to the chair of surgery at Glas- 
gow, where he carried on his epoch-making 
researches on the nature of infection in wounds 
and their prevention. When he first began his 
work in the Glasgow Infirmary, he was dis- 
tressed to find that with every precaution then 
known his mortality in amputation cases was 
45 per cent. He was greatly impressed by the 
fact that simple fractures healed kindly, but 
the compounded ones developed sepsis and 
required amputation; also, that if a wound 
healed without pus the patient did well. He 
became convinced that pus was caused by in- 
fection, and if this could be prevented the 
patient would do well. 

Lister, being a student of the literature, soon 
read of Pasteurs discoveries in lactic add fer- 
mentation. He realized immediately that if 
infection could be prevented at the start pus 
would not form in the wound. Because the 


wound could not be sterilized by heat he 
looked for other means. He learned that sew- 
age treated with carbolic acid, in the city of 
Carlisle, did not putrefy. This led him to try 
the effect of carbolic acid in varying strengths 
as a disinfecting agent to combat germs which 
had invaded the operative field. He used vari- 
ous dressings saturated with dilute solutions 
of the acid, and because he was sure that these 
bacteria were in the air and entered the wound, 
he had the operating room and the operative 
field sprayed with a carbolic acid solution 
before each operation. 

Lister began his work in antisepsis in 1865. 
The treatment of his first patient with a 
compound fracture did not succeed, but that 
of his second resulted in healing by primary 
union- During the next two years he accumu- 
lated an increasing number of successful op- 
erations and in 1867 published two revolu- 
tionary papers in the London Lancet, entitled: 
“On a New Method of Treating Compound 
Fracture, Abscess, etc., with Observations on 
the Condition of Suppuration” and “On the 
Antiseptic Principle in the Practice of Sur- 
gery.'^ In these remarkable publications he 
demonstrated in convincing fashion the amaz- 
ing improvement in wound healing hy the use 
of his antiseptic techniques. 

Strangely enough Listers ideas did not re- 
ceive immediate acceptance hy the British sur- 
geons, and men like Lawson Tate, who had 
remarkably good wound healing, because he 
was very insistent on the thorough cleansing 
of his hands before he operated, ridiculed the 
“new f angled listerism.’' But by 1868 Lucas 
Championierre, in France, had followed Lis- 
ter, and the new doctrine was accepted by 
Nussbaum in Germany. 

In 1877, Robert Koch, the great German 
bacteriologist, published his monograph, “The 
Cause of Infection in Wounds,” in which he 
showed for the first time the specificity of the 
different kinds of bacteria which caused infec- 
tion, and that each organism had characteris- 
tics which gave distinct clinical pictures. More 
and more it became evident that antisepsis was 
only a partial solution of the problem of infec- 
tion, and that the prevention of the introduc- 
tion of bacteria into the wound was more imi 
portant than trying to kill the bacteria, oi 
prevent their growth, after they had enterec 
the wound— in other words, the principle o: 
asepsis. Surgeons began to appreciate the fac 
that if the pathogenic organisms could be elim 



Chapter L History of Surgery 


inated from the operative field the chances of 
clean around healing would be far greater than 
was possible otherwise. The first of the anti- 
septic techniques of Lister to be discarded was 
the carbolic spray which was denounced by 
von Bruns, in 1880, in his pronouncement, 
"Fort mit der Spray.” Von Bergmann realized 
that if the living tissues of the patient could 
not be sterilized by heat, everything else which 
came in contact with the wound except the 
surgeon’s hands could be, and so in 1886 he 
detised the method of steam sterilization which 
has become a sme qua non in all modern op- 
erating rooms. It was Halsted who introduced 
the use of sterile rubber gloves, freeing the 
surgeon, and his assistants, from the onus of 
contaminating their hands. In 1900, Hunter of 
the Charing Cross Hospital in London, was 
the first to introduce the use of the gauze 
mask by the operating team. 

World recognition came to Lister while he 
was still active. After he moved from Edin- 
burgh, where he had succeeded Syme, to the 
Professorship of Surgery in Kings College in 
London, he was the first surgeon to be made a 
peer of the British Empire. He was showered 
with honors from all over the world. He was 
justly called, 'The Great Benefactor.’' Among 
his most outstanding characteristics were his 
innate modesty and his insistence on giving 
credit to the men who he thought had led 
to his discoveries in the causes of wound infec- 
Tion, especially Pasteur and Semmelweis. 

With the discovery of the role of bacteria 
hn wound infection and the benefits of previ- 
^ously established anesthesia, surgery made un- 
fprecedented progress. But even with the 
iacceptance of asepsis in the leading surgical 
clinics of the world, infection of clean opera- 
itive wounds continued, although to a far less 
{degree to be sure, owing to factors not ade- 
quately appreciated. These were the inability 
fo sterilize the skin, inadequate hemostasis, un- 
necessary tissue damage due to the use of 
heavy blunt-nosed hemostats which crushed the 
hssues surrounding the bleeding vessels, and 
especially the use of heavy grades of catgut 
igature and suture material which acted as 
rritating foreign bodies and culture media for 
Le bacteria which escaped the aseptic 
technique. 

, It was the great Swiss surgeon, Theodore 
^ocher, who first demonstrated the importance 
Ae m^culpus technique of wound repair, 
consisted : of,, painimum tissue ' damage at- 


tained by the use of finer ligature and suture 
material, the material being nonabsorbable 
silk. In a period of seven weeks, in 1887, he 
found that in 31 patients upon whom opera- 
tions were performed wound infection occurred 
in 29 in whom catgut had been employed. 
When silk replaced catgut infections ceased. 
The paper in which he described this remark- 
able improvement in wound healing was pub- 
lished in an obscure Swiss journal and did not 
attract the attention it deserved. 

One of Kochers great admirers was William 
S. Halsted, the first Professor of Surgery at the 
Johns Flopkins Medical School. He had been 
a brilliant rapid operator as a young surgeon 
in New York City, but during an enforced 
period of retirement and contemplation, before 
he went to Baltimore, he revised his ideas of 
surgical technique and surgical training, which 
resulted in his becoming a careful, deliberate 
operator, with a meticulous regard for mini- 
mizing tissue damage by the use of sharp knife 
dissection, fine pointed hemostats, fine needles, 
and finer grades of silk than were previously 
employed for his ligature and suture material. 
Like Lister and Kocher he gave great attention 
to the study of wound healing and wound 
repair, and established the principle which 
after some twenty-five years of trial and error 
he described in a publication appearing in 
1913. 

Halsted’s paper is so epoch-making that sev- 
eral quotations are here included. He definitely 
improved on Kochers technique. He stated: 

"Our method of employing silk clifFers quite 
essentially from Professor Kocher’s. The silk 
which we use is much finer than his, and we 
rely on transfixion to prevent the ligature from 
slipping. 

T am unable to say precisely when it was 
that I definitely substituted silk for catgut. It 
must have been earlier than 1883, for in that 
year, or in 1882, Warmbrum, Quilitz & Co. of 
Berlin made for me, in glass, bobbins of my 
designing, to be held in the left hand of the 
operator during the act of ligating vessels. . . . 

I have employed them continuously from the 
time of their introduction to the present. . . . 
Black silk was selected in preference to white 
because it was easier to see on the glass bob- 
bins, and in the fresh wound, and more easily 
identified in the healed wounds. . . . The fol- 
lowing winters, 1887-1889, in my experiments 
on the thyroid gland, I employed exclusively 
the black silk, just as we do to-day, ever since 



7 


Wound Care and Wound Repair 


the opening of the Johns Hopkins Hospital 
twenty-five years ago. . . . The relatively high 
cost of catgut, its bulkiness, the inconveniences 
attending its use and sterilization, its inade- 
quacy, the uncertainty as to the time required 
for its absorption, and the reaction which it 
excites in a wound, induced me to discard it 
for clean wounds, both of the human subject 
and of animals. . . . That surgeons obtained 
excellent results with silk even when gloves 
were not worn one may convince himself by 
the papers of Kocher, Haidenhain and Hagler. 
Now that gloves are invariably worn, the re- 
sults with silk, properly employed, are so per- 
fect that I believe its adoption will ultimately 
become general.^^ (This was a prophecy ful- 
filled many years later, as indicated in sub- 
sequent discussion.) 'The surgeon who desires 
to use silk, and who, after giving it a trial, 
finds that the results are not as good as with 
catgut, may I think quite surely attribute his 
failure to himself-to faulty technique. By 
faulty technique I do not mean merely breaks 
in asepsis. 

"One should not of course use silk for ligat- 
ing and suturing in the presence of infection. 
Nor should one bring parts together under such 
degree of tension as to cause necrosis of the 
suture line, or interfere greatly with the blood 
supply, for nothing is gained by so doing, and 
decided harm may result. Healing is menaced 
when the circulation of the tissues to be united 
is impaired. . . , The silk to be employed should 
never be coarser than necessary. It is useless 
to employ a thread for suture which is stronger 
than the tissue itself. ... A greater number 
of fine stitches is better, as a rule, than a few 
coarse ones. . . . Avoid if possible the combined 
use of silk and catgut in a wound/’ This latter 
sentence he underlined, but did not give rea- 
sons for the admonition. The significance of the 
statement lies in the fact that catgut predis- 
poses to bacterial growth, and if infection de- 
velops in such a wound the silk sutures may 
act as foreign bodies, to be extruded later. 

HalsteTs surgical philosophy regarding 
wound repair with silk is epitomized in his dic- 
tum, given without explanation, "Silk should 
not be used that does not break easily/’ Sur- 
geons who have not used silk properly cannot 
understand this. 

In this same paper, Halsted stated, “In the 
winter of 1889“”! 890—1 cannot recall the 
month— the nurse in charge of my operating 
room complained that the solutions of mercuric 


chloride produced a dermatitis of her arms and 
hands. As she was an unusually efficient 
woman, I gave the matter my consideration, 
and one day in New York requested the Good- 
year Rubber Company to make as an experi- 
ment two pairs of thin rubber gloves, with 
gauntlets. On trial these proved to be so satis- 
factory that additional gloves were ordered. 

. . . After a time the assistants became so ac- 
customed to working in gloves that they also 
wore them as operators and would remark 
that they seemed to be less expert with the 
bare hands than with the gloved hands. . . . 
Thus the operating in gloves was an evolution 
rather than an inspiration or happy thought. 

. . . Rubber gloves must be worn by all con- 
cerned in the operation.” 

The use of the modern and recently discov- 
ered bacteriostatic and bacteriolytic antibiotics 
has revolutionized the treatment of medical and 
surgical localized and blood stream infections, 
but to depend upon the local instillation of 
these preparations and the shotgun doses of 
these antibiotics to replace careful aseptic and 
atraumatic wound repair is bad surgical prac- 
tice. The normal period of wound repair by 
first intention-three to four days of lag period, 
followed by ten days of fibroplasia-cannot be 
improved or accelerated. Many attempts have 
been made to introduce so-called wound heal- 
ing substances for shortening Nature’s healing 
process. This was well illustrated during World 
War II, when the Committee on Burns and 
Contaminated Wounds of the National Re- 
search Council was deluged by well-meaning, 
but ignorant, persons recommending everything 
from chlorophyll to jumping Mexican bean 
extract— all of which, of course, were useless— 
to be used in hastening the healing of war 
wounds. The surgeon’s constant effort should 
be to eliminate the factors which interfere 
with and prevent Nature’s normal processes of 
wound healing. These are: tissue damage, and 
the failure to remove damaged or dead tissue; 
failure to maintain the blood supply to the 
wound borders and the adjacent tissues; failure 
to prevent the accumulation of blood clot and 
exudate in and between the wound surfaces: 
which tend to keep the wound margins apart: 
the introduction of heavy suture and ligature 
material which act as foreign bodies; and fail 
ure to maintain asepsis. | 

With the great example of Lister in hij 
epoch-making discoveries in wound infectiori 
in his laboratory, it is strange that it was no|: 



8 Chapter L History of Surgery 


until 1923 that the first bacteriologic labora- 
tory, as part of the surgical clinic, was organ- 
ized at the Columbia Presbyterian Hospital 
Dr. Frank L. Meleney, a trained surgeon and 
bacteriologist especially interested in wound 
infections, was in charge of this laboratory. His 
original discoveries in hemolytic streptococcus 
gangrene, postoperative, progressive, bacterial 
S} nergistic gangrene, and the progressive un- 
dermining ulcer and its treatment by the use 
of zinc peroxide, as well as his discovery of 
the antibiotic bacitracin, have made him and 
this laboratory internationally known. He has 
trained many surgical residents who have or- 
ganized similar laboratories in other university 
clinics. Such men and such laboratories make 
a surgical service wound conscious and jealous 
of its results in primary wound healing. 

HEMOSTASIS 

Wounds and the attending loss of blood 
comprised the primitive surgeon s great problem. 
These were first treated, in prehistoric times, 
by pressure, and bandaging with tamponade- 
measures which were later combined with the 
use of styptics and astringents. Later the actual 
, cautery and boiling oil methods were employed. 

; This was continued through the centuries until, 
and after, the time of the French surgeon, 

( Ambroise Pare. 

I It was probably in the latter period of the 
Alexandrian School, and not until then, that 
\ more definite measures to control and prevent 
^1 hemorrhage originated. Torsion of vessels and 
jjthe ligature were undoubtedly invented in the 
Alexandrian School, for their use was first in- 
troduced to Roman surgery hy Eulpistus of 
I Alexandria, shortly before the beginning of 
I the Christian Era. 

. Three great encyclopedists and compilers of 
;.the first three centuries, a.d., Celsus, Galen 
hnd Oribasius, transmitted Greek and Alexan- 
Hrian medicine to posterity. It was Celsus who 
feave the first accurate account of the use of 
,me ligature. He lived in Rome about the he- 
, ^nning of the first century. Whether he was 
\ physician is debatable, hut he was an able 
and scholarly compiler. He wrote an encyclo- 
pedia of the arts and sciences of his time, with 
|ix sections on medicine and two on surgery. 
|n his discussion, “The Proper Manner of Ar- 
ie^ing Hemorrhage,'' he says: 

I ‘Tf there is fear that there may he bleeding 
|ne should fill the wound with dry lint, place 
|vei it a apon^e wrung out of cold water, and 


press upon it with the hand. If the blcedi] 
still continues, it is advisable to change tl 
stuffing of lint somewhat frequently, and 
this step proves ineffective, then lint moistcnc 
with vinegar may be tried, for this liquid ac 
energetically in arresting hemorrhage. Son 
physicians, indeed, actually pour it into th 
wound. There is strong objection, however, t 
the use of an agent, which, like \anegar, arrest 
the bleeding too completely, for it is aiu to sc 
up afterwards an intense inflammation of th( 
parts. The same reasoning applies with ever 
greater force to the employment of corrosivej 
and caustics which produce an eschar. Despite 
the effectiveness of most of these in arresting 
hemorrhage their use should be discontinued. 

“Finally, if the bleeding continues it vvil! be 
necessary to grasp the vessel, from which the 
blood is escaping, and to ligate it in two places, 
close to the wound, and then divide the vessel 
between the two ligatures, in order that it may 
retract (both the new orifices having been al- 
ready closed by the ligatures). If the circum- 
stances are such that the plan just recom- 
mended cannot be carried out, it will then be 
advisable to apply the red hot cautery to the 
bleeding vessel." It is interesting to conjecture 
why the ligature was used almost as a last re- 
sort— probably because the technique of apply- 
ing it was still in the formative period, 

Heliodorus who lived in the Greco-Roman 
period at the beginning of the second century, 
A.D., in discussing the operation for hernia, 
wrote: “We ligature the larger vessels, but as 
to the smaller ones, we catch them with hooks 
and twist them many times, thus closing their 
mouths." 

Notwithstanding the knowledge at that time 
of the use of the ligature, it was not employed 
for amputations, operations which in those 
early days were not performed until gangrene 
had set in, when the incision was made distal 
to healthy tissue. However, Heliodorus, in dis- 
cussing amputations, had this to say: “The 
hand or foot is amputated if gangrene takes 
place, or necrosis of an extremity from any 
other cause. The lower portions of an extrem- 
ity are removed with less danger, the parts 
above the ankle or knee with greater risk, on 
account of the great danger of hemorrhage in 
most cases, because of the division of large 
blood vessels." 

Galen (130-200 a.d.) advised the ligation of 
arteries when hemorrhage could not he con- 
trolled otherwise, and is said to have used it 



Hemostasis 


9 


later for amputations. He told wKere he got his 
Celtic linen thread for his ligatures— “at a shop 
on the Via Sacra, between the Temple of 
Rome and the Forum,” a shop near his house 
on the Via Sacra, by the Temple of Peace. 

Paulus Aeginata copies Galen in his treat- 
ment of hemorrhage, but adds: ‘Tou may know 
whether it is a vein or an artery that pours 
forth the blood from this, that the blood of an 
artery is brighter and thinner and is evacuated 
by pulsations, whereas that of the vein is 
blacker and without pulsations.” 

For the next 1000 years of the Dark and 
Middle Ages surgery sank to lower and lower 
levels. Anything which had to do with the 
shedding of blood was assigned to the barber- 
surgeons, who had no knowledge of the liga- 
ture, and the cautery, caustics and astringent 
ointments dominated the treatment of hemor- 
rhage. 

Lanfranchi of Milan became a political exile, 
spending most of his professional life in France. 
He became associated with the French surgeon 
Jean Pitard in the College de St. Come, which 
the latter had founded in Paris in 1306. The 
better educated surgeons of Paris tried to ele- 
vate the art of surgery and separated them- 
selves from the barber-surgeons. They wore 
long robes, whereas the barber-surgeons wore 
short robes, and therefore were called ‘‘the sur- 
geons of the long robe,” Lanfranchi wrote a 
notable treatise on surgery, the Chirurgia 
Magna, and in it discussed the problem of 
hemorrhage. He distinguished between venous 
and arterial bleeding, and advised the use of 
a styptic with digital compression for an hour, 
and for severe cases the use of the ligature. 

Henri de Mondeville, whom we have dis- 
cussed in his role as a protagonist of clean 
wound repair, was a contemporary of Lan- 
franchi and an advocate of the ligature. He 
wrote: 'Distinguish always between oozing 
hemorrhage, hemorrhage by jets, and that 
which pumps out of an inward wound.” He 
points out the fault of the cautery in stopping 
bleeding— that when the eschar separates the 
hemorrhage may recur, and the wound must be 
disturbed a second time for another application 
of the cautery. "Let the vessel be isolated from 
the surrounding parts with the knife, and tor- 
sion be used with ligature. Do not, as Galen 
teaches, allow the wound to bleed with the 
notion of preventing inflammation; for you will 
only weaken the patienFs vitality, give him 
two diseases instead of one, and favor sec- 


ondary hemorrhage. When your dressings have 
been carefully made, do not interfere with 
them for some days. Do not pull your dressings 
about, Nature works better alone.” 

Guy de Chauliac, who did so much to reject 
the teachings of Hugo, Theodoric and Henri, 
in primary wound healing, was no more con- 
structive in his dealing with hemostasis, for he 
still preached the use of styptics and the 
cautery. 

It was not until Ambroise Pare (1510-1590), 
the most famous of the French surgeons, some- 
times, but questionably, called the Father of 
Modern Surgery, appeared as the great war 
surgeon of his time that the use of the ligature 
was restored, and the use of the cautery and 
boiling oil for the control of hemorrhage was 
discarded. He was at first an apprentice in a 
barber shop, but later came to Paris and served 
as a dresser in the Hotel Dieu, a hospital in 
that city. In 1537 he became an army surgeon 
and in the many campaigns in which he served 
he had ample opportunity to study gunshot and 
other war wounds, and wound healing. His 
modesty is epitomized in his very famous, old 
French saying, "Je Fai pansay, Dieu le guerit” 
(I cared for him, God cured him). He tells of 
his conversion from the use of the cautery and 
boiling oil to the more kindly care of wounds: 

"In the year of our Lord 15^6, Francis, the 
French King, sent a puissant army beyond the 
Alps. In the conflict there were many wounded 
on both sides with all sorts of weapons, but 
chiefly with bullets. I will tell the truth, I was 
not very expert at that time in matters of: 
Chirurgy; neither was I used to dress wounds 
made by gunshot. Now I had read in John de 
Vigo that wounds made by gunshot were 
venenate or poisoned, and that by reason of 
the gunpowder; wherefore for their cure it was 
expedient to burne or cauterize them with oyle 
of Elders scalding hot, with a little Treacle 
mixed therewith. 

"But for that I gave no great credit, neither 
to the author nor the remedy, because I knew 
that caustics could not be poured into wounds 
without excessive paine; I, before I would run 
a hazard, determined to see whether the 
Chirurgions, who went with me in the Army: 
used any other manner of dressings to these 
wounds. I observed and saw that all of theirj. 
used that method of dressing which Vigo prel' 
scribes; and that they filled, as full as the;|’' 
.could, the wounds made by gunshot with tent| 
and pledgets dipped in the scalding oyle a| 



10 


Chapter 1. History of Surgery 


the first dressings; which encouraged me to 
doe the like to those who came to be dressed 

of me. 

“It chanced on a time that by the reason of 
the multitude that were hurt I wanted this 
ovle. Now because there were some few left 
to be dressed, I was forced that I might seem 
to want nothing, and that I might not leave 
them undressed, to apply a digestive made of 
the yolk of an egg, oyle of Roses and Turpen- 
tine. I could not sleep all that night, for I was 
troubled in minde, and the dressing of the 
precedent day (which I judged unfit) troubled 
my thoughts; and I feared that the next day I 
should find them dead, or at the point of 
death, by the poison of the wound, whom I 
had not dressed with the scalding oyle. There- 
fore I rose early in the morning, I visited my 
patients, and beyond expectation, I found such 
as I had dressed with a digestive only, free 
from vehemence of paine to have had a good 
rest, and that their wounds were not inflamed 
nor tumyfied: but on the contrary the others 
that were burnt with the scalding oyle were 
feverish, tormented with much paine, and the 
parts about their wounds were swolne. 

“When I had many times tryed this on divers 
others I thought this much that neither I nor 
any others should ever cauterize any wounded 
with gunshot.’’^ 

■ Why tourniquet control of bleeding was not 
mentioned earlier in the writings of surgeons 
•is very difficult to understand, for pressure was 
bne of the earliest methods mentioned in Egyp- 
tian and Greek texts. But apparently the first 
Reference to its use was the introduction of 
[the tourniquet by Morel, and of the screw 
burniquet by Petit, in 1674 a.d. It was suc- 
leessfully employed in a thigh amputation at 
dhe Hotel Dieu in 1688. Speaking of pressure, 
i -jiston, the giant Scot surgeon, is said to have 
Compressed the femoral vessels with his left 
iaand while he amputated the thigh with his 

I Von Esmarch, of Kiel University and a great 
|ailitary surgeon, standardized compression for 
|uTgical hemostasis, when, in 1873, he devised 
|ie multi-fold elastic rubber bandage, which 
|as since been called by his name. 

I There is some uncertainty as to who first in- 
Jented and used hemostatic forceps or clamps— 
;| ^ These paragraphs were taken from ''The Works 
I That Famoiis Chirargion, Anibroise Parey/^ Tram- 
silted out of the Latin and compared with the French 
Th. Johnson, if Folio, London, T. Coates & R 
';|!0«ng, 1634- 


Eugene Koeberle, an Alsatian surgeon, or Jules 
Pean, of Paris, in the early lK7()'s. I’or many 
years following their introduction, hemostats 
were blunt-nosed affairs that criishccl more 
than the blood vessels. It was 1 lalsted who in- 
troduced the finc-pointccl hemostats that caused 
so much less trauma in the u'ounds. The use 
of the Halsted hemostats in llie repair of 
wounds, with llalstccrs silk technique, pre- 
vents unnecessary immediate, as well as later, 
bleeding into the wound. 

The bleeding tendency, which in the past 
had been so dreaded l)y the surgeon, has in 
recent years been better understood and con 
trolled. Blood transfusion in certain jviticmts 
having prothrombin deficiency and delayed 
clotting time has been used eirccti\'ely. In llie 
deeply jaundiced patient, in whom the bleeding 
tendency after surgery was so catastrophic, the 
use of vitamin K for several clay's before opc‘ra 
tion has very largely removed this ha'/.arcl, and 
has made radical operations for the repair of 
common duct obstruction and for pancreatic 
tumors possible. 

ANESTHESIA 

The search for a substance, or combination 
of substances, which would relie\x* the pain 
of the surgical patient, without danger of kill- 
ing him, harks back to the earliest diiys of sur 
gery. Many centuries before the Ghristian i‘ra 
the wild Scythians used hemp vapor to bring 
on unconsciousness. Manclragora was described 
by Pliny, in 70 a.d,, in the following words: 
Tt has a soporific power on the faculties ol' 
those who drink it. Half a cup is the usual do,se. 
It is drunk against serpents, and before cut- 
tings and puncturings lest they be felt.'' 

During the Middle Ages the sleep-producing 
sponge-spon^ia somnifera-^was used. I lugc^ of 
Lucca, the great protagonist of primary wound 
healing, was quoted by his son, lliccidcjric, in 
its elaborate preparation as follows: 

Take of opium and the juice of the unripe 
mulberry, of hyoscyamus, of the juice of the 
hemlock, of the juice of the leaves of the man- 
dragora, of the juice of the woody ivy, of the 
juice of the forrest mulberry, of the seeds of 
lettuce, of the seed of the burdock which has 
large and round apples, and of the water hem- 
lock, each one ounce. Mix the whole of these 
together in a brazen bowl, and then in it place 
a new sponge and let the whole boil, and as 
long as the sun on the dog days, till the sponge 
consumes it all, and let it be boiled away in it. 



Anesthesia 


11 


When there is need of it place the same sponge 
into warm water for an hour, and let it be ap- 
plied to the nostrils till he who is to be oper- 
ated upon has fallen asleep, and in this state 
let the surgery be done. When this is finished, 
in order to rouse him, place another sponge, 
dipped in vinegar, frequently to his nose or 
let the juice of fenigreek be squirted into his 
nostrils. Presently he awakens/' 

Such an elaborate mixture should have 
done something to the patient, but the fact 
that it fell into disuse was good proof that it 
was not effective. 

Before and after Hugo’s time, opium and al- 
cohol were used to produce unconsciousness, 
but if given in quantities sufficient to produce 
anesthesia the risk to the patient undergoing 
crude and shocking surgery, accompanied by 
great loss of blood, was considered too danger- 
ous by most surgeons. 

In the Trustees’ Room in the London Hos- 
pital, which the writer visited in 1930, there 
hangs a large bell, similar to the ones on our 
old steam locomotives. Under it is a plaque, 
with the following inscription: 'This bell for- 
merly hung in the front hall of the hospital. 
It was sounded to summon the orderlies to con- 
trol the patients undergoing operation, before 
the discovery of anesthesia.” Left to the imag- 
ination was the terror of those about to be op- 
erated upon, and the dreadful memories of 
the patients who had experienced the ordeal. 

In 'The Diary of a Surgeon in the Year 
1751-1752,” John Knyveton tells of his ex- 
periences as a medical student in one of the 
hospitals in London. His first introduction to 
the hospital took place one morning when he 
went to register in Anatomy. He says: "Doctor 
Urquehart was then performing an amputation 
of the thigh upon a porter, brought in that 
morning from Covent Garden with a com- 
pounded fracture of the left femur, the result 
of a kick from a horse. . . . The incisions of 
Doctor Urquehart were placed high upon the 
thigh. There was considerable trouble from 
the mass of muscle to find the arteries, which 
the Doctor for his own advancement wished to 
ligature with cords, though I learn that in such 
Institutions it is quite common to cauterize 
them only, with a hot iron or with boiling tar. 
Thus from the plunging of the patient, who 
seemed unable to comprehend that it was done 
for his own good, and the clumsiness of the 
Infirmary surgeon, Mr, Jamie, ten minutes 
elapsed before the leg lay on the floor, and 


much blood was shed. . . , The patient being 
a poor man had few friends able to make him 
drunk, and so he being a well developed speci- 
men many ropes were necessary to control his 
struggles. ... I wished to enquire what the 
chances of recovery were, knowing that in such 
a place they must surely he very small, if in- 
deed existent at all, but after one attempt gave 
it up as the screams of the porter made speech 
impossible. . . . The next morning I hear that 
the porter whose leg was removed yesterday 
is dead.” 

It was not until the beginning of the nine- 
teenth century that any real progress was 
made, and not much of that. In 1800 Sir 
Humphrey Davy, the distinguished English 
chemist, experimented on himself with nitrous 
oxide gas, and made the following comment: 
"As nitrous oxide, in its extensive operation, 
appears capable of destroying physical pain, it 
may probably be used wdth advantage during 
surgical operations in which no great effusion 
of blood takes place.” Note the recognition of 
the hazard of hemorrhage in the state of un- 
consciousness produced by a noxious drug. 

But it was not until 1844 that this suggestion 
was made use of. Whether it was known to 
Horace Wells, a dentist in Hartford, is not 
certain. But in that year he was successful in 
the use of this gas in extracting teeth. Latei 
in the same year he demonstrated its use, but 
not successfully, at the Massachusetts General 
Hospital in Boston. Following the death of one 
of his dental patients, Wells gave up the use 
of the gas, and, probably brooding over thi: 
catastrophe, committed suicide. 

The next anesthetic agent to become knowi 
as a successful one was ether. This was firs 
described as a chemical agent in 1540, b' 
Valerius Cordus, and was named ether b; 
Frobinius in 1730, in his description of it 
preparation. It had been used at times to reliev 
colicky pains, and in 'ether frolics” by student: 
But the first surgeon to use it as an anestheti 
for an operation was Crawford W. Long, c 
Danielsville, Georgia. On March 30, 1842, h 
removed a cystic tumor from the neck of K 
patient, James Venable, under ether ane: 
thesia. Unfortunately for him and medical hi 
tory he did not publish a report of this ah 
other cases, but his use of ether as an anesthet 
was later verified and vouched for by the do 
tors in his locality, during the controversy th! 
developed over the question of priority. But 
Welch said later: 'We cannot assign to hi 



Chapter 1. History of Surgery 


Hny influence upon the historical development 
of our knowledge of surgical anesthesia, or any 
share in its introduction to the w^orld at large. 

William T. Morton, a dentist and a former 
partner of Horace Wells, had learned some- 
thing of the use of nitrous oxide. He later 
began the study of medicine, while still practic- 
ing dentistry. One of his instructors was 
Charles T. Jackson, an able chemist, who 
taught him the properties of chloric ether. 
Morton used it in filling a tooth in July of 
1844. He then learned from Jackson that sul- 
furic ether was also an anesthetic, and he used 
it in extracting a deeply rooted bicuspid tooth 
from one of his dental patients. Later that year 
he called on Dr. John Collins Warren, of the 
Massachusetts General Hospital, to persuade 
him to let him give this sulfuric ether to one 
of Warren's surgical patients, but did not dis- 
close the name of the new drug to be used. 
The operation took place on October 16, 1846, 
on what is called Ether Day. In the historic 
Ether Amphitheater of the Massachusetts Gen- 
eral Hospital, Warren removed a vascular 
tumor located below the jaw on the left side 
of the neck, in a few minutes, while the pa- 
tient was unconscious. As the patient was wak- 
ing Warren exclaimed, '^Gentlemen, this is no 
humbug.” The next day Morton administered 
i:he anesthetic for Dr. Hayward, who removed 
, a large lipoma of the shoulder. Henry J. Bige- 
, hw, the other Senior Surgeon of the hospital, 

.| jmproved on the method of administering 
^.)ther, and on November 18, 1846, he pub- 
y^shed the paper in the Boston Medical and 
’^j>urgical Journal, announcing to the world the 
uccessful use of ether as an anesthetic agent, 
ivhich Weir Mitchell later called ‘'the death 
I if pain.” 

’ I Morton tried to patent sulfuric ether under 
'.he name of “letheon,” and did not announce 
true nature until 1847. He got into a bitter 
'pntroversy with his former preceptor, Jackson, 
jjver the legal rights of the discovery, and later 
|ied an embittered and unhappy man, 

I The high character and reputation of War- 
|n and Bigelow, and the hospital where ether 
|as first publicly demonstrated, accounted in 
|rt for the immediate acceptance of sulfuric 
|her as a general anesthetic. Liston in London 
|ed the new drug as an anesthetic in doing a 
|igh amputation in December, 1846. Syme 
liok it up in Edinburgh in 1 847, and the great 
lissian ^geon, Pixogoff, published a manual 
etherization the Oliver Wendell 


Holmes coined the terms “anesthesia" and “an- 
esthetic.^’ 

In 1847, the Professor of Obstetrics in Edin- 
burgh, Sir James Y. Simpson, tried ether in his 
practice, but on November 4 of that \’ear he 
tried the use of chlorofornu Liebig’s disecnx'ry, 
in delivering a woman, and was so impressed 
with the easier administration of the drug, and 
the earlier recovery, in other patients, tluii a 
week later he published his results in a paper 
entitled, “Account of a New /\nesthetic 
Agent.” 

Thus, with the discoveries of ether and 
chloroform, and their universal acceptance as 
effective anesthetic agents, a new era in sur- 
gery was born. This was doubly significant, for 
it not only relieved the patient undergoing 
operation from the torture of pain, and the 
surgeon inflicting it, hut it initiated llte era of 
deliberate and careful surgery on human {pa- 
tients and freed the laboratory workers in ex- 
perimental physiology and surgery from the 
stigma of inflicting pain and cruelty on vivi- 
sected animals. But so many surgeons of dmt 
period had been accustomed to rapid and 
sleight of hand operating that the advantages 
of deliberate surgery were slow in developing. 
However, anesthesia opened up tremendous 
possibilities in exploring new and hitherto in- 
accessible fields, that previously had l)een con 
sidered too hazardous, because of the struggles 
of the patient. 

Since the discoveries of ether and chloroform, 
the evolution of the science of anesthesia has 
been a progressive refinement in general in- 
halation, local and conductive infiltratitin, 
spinal, intratracheal, and in recent years, in- 
travenous anesthesia, with an increasing num- 
ber and variety of agents, singly and syner- 
gistically administered. 

The invention of the hypodermic syringe in 
its use in administering sedatives and in anes- 
thesia is important. Who first invented it is 
uncertain, but it was first introduced in Eu- 
rope, as a medical instrument, by Francis Rynd 
in 1845, and in America by Fordyce Barker in 
1856. Thus, we see that the decade of 1840- 
1850 was of the greatest significance in the 
battle against pain. 

Nitrous oxide combined with oxygen, to 
combat cyanosis in inhalation anesthesia, was 
first employed by Andrews of Chicago in 1868. 
Its use was revived by Goklmann in 1900, 
Crile popularized it in 1901, by giving a pre* 
liminary injection of scopolamine and mor*' 



Training of the Surgeon 


phine, and called this method anoci-association. 

Following the discovery of cocaine by Anrep 
in 1879, and Roller' s use of it in eye surgery in 
1884, Halsted developed all its possibilities 
in nerve block conduction and local infiltration 
anesthesia during the next two years, while 
he was working in New York City. Later pro- 
caine hydrochloride, discovered by Einhorn in 
1905, replaced cocaine because of its less toxic 
effect and its freedom from the danger of ad- 
diction if used repeatedly. 

Spinal anesthesia was popularized in this 
country by Matas in 1899, and in France by 
Tuffier in 1900. Stovaine, which at one time 
was used for its induction, has been replaced 
by procaine as a vehicle for the safer form of 
continuous, or fractional, spinal anesthesia in 
providing complete relaxation for operations 
below the diaphragm. 

Rectal ether anesthesia was first successfully 
induced by Sutton, at the Roosevelt Hospital 
in New York, in 1908, and refined by Gwath- 
mey in 1913. But this form of general anes- 
thesia has been discontinued for the more ef- 
ficient forms of inhalation, spinal and in- 
travenous anesthesia. 

The use of other gases for general anesthesia, 
after the introduction of nitrous oxide, was 
started by Luckhardt of Chicago, in 1922, with 
the highly volatile ethylene. This was more 
recently followed by cyclopropane. But these 
very volatile gases carry with them the danger 
of greater explosiveness and should not be 
used except in operating rooms especially 
equipped to carry off electric spark. 

Intratracheal anesthesia, especially indicated 
for thoracic and cardiac surgery, has become 
increasingly useful. It was made possible by 
the discovery by Meltzer and Auer, in 1909 at 
the Rockefeller Institute, of intratracheal in- 
sufflation of air through a tube passed into the 
trachea of experimental animals which pro- 
vided “continuous respiration without respira- 
tory movement.'' It has also been effectively 
used in operations in which any amount of 
blood or mucus in the mouth or throat is liable 
to be aspirated. 

Intravenous anesthesia, induced by a variety 
of drugs, is the most recent development in the 
field of general anesthesia. Pentothal sodium 
is the drug most frequently used. The rapid 
loss of consciousness, within a few seconds 
after the intravenous injection (usually into 
the median basilic vein), and the quick recov- 
ery without nausea and confusion are boons 


13 

to the patient, who can be put to sleep and will 
awaken in his own bed and room. 

One of the greatest advances in anesthesia 
in recent years has been the development of 
the residency training program in anesthesi- 
ology. Physicians trained in medicine and 
physiology, entering this field of medical sci- 
ence are given intensive training in the admin- 
istration of all forms of anesthetics and at the 
end of three years are qualified to take the 
examinations of the American Board of Anes- 
thesiology. Thus, qualified physician anesthe- 
siologists are rapidly replacing the less experi- 
enced nurses and interns who in the past had 
given the anesthetics in our hospitals. The 
many forms of anesthesia, with the many kinds 
of modalities used to produce them, require 
a knowledge of medicine and physiology for 
the greater safety of the patient. 

Furthermore, this training stimulates those 
that have had it to go into the research side of 
anesthesiology, with, the result that new ve- 
hicles and new methods of administration are 
increasing. One of the efforts of these investiga- 
tors should be to simplify, rather than to elab- 
orate, the number of drugs and methods of 
administering them to the patients before, 
during and after the operation. In recent years 
there has been a tendency to use too many 
drugs, in different routes, with the result that 
cardiac and respiratory complications during! 
and after operation have increased because of 
the polypharmacy of anesthesia. 

TRAINING OF THE SURGEON 

The beginnings of surgical training are in- 
definite, and the vagaries, advances and reces- 
sions of it are many and involved; but why and 
when they were involved were closely related 
to the historical relations of medicine and 
surgery. 

In the hippocratic era of Greek medicine disi 
eases amenable to the simple surgery of that 
time were few. The physicians trained in the 
Coan and the Cnidian Schools practiced botli 
medicine and surgery, and followed the teach 
ings of the great master, Hippocrates, and hii 
predecessors, which had evolved from th| 
priests of the aesculapian temples. There wa* 
no superiority of physician over surgeon. j 

Hippocrates gave the first authentic instrua 
tions to the surgeons of historical times. Hi 
described the best position and the best lighj 
ing for the surgeon; he stated t hat th ^ej urgeoj 
should clean his hands and fingernails car^ 



Chapter L History of Surgery 


fully and that he should use clean spring 
water for washing wounds. In the oath at- 
tributed to him, he gives the rules of conduct 
and ethical behavior that have been the standard 
for both physician and surgeon ever since his 
time, and is sworn to by medical students, as 
they graduate, all over the world. 

This same attitude of mutual respect for 
medicine and surgery was true in the Alexan- 
drian School, where anatomy and physiology 
made their first advances, owing to the fact that 
vivisection was permitted on criminals con- 
demned to death. This same attitude of respect 
held true in the Greco-Roman period, but 
rapidly deteriorated during the later centuries 
of the degenerate and disintegrating Roman 
Empire. Galen practiced both medicine and 
surgery, but gave up his interest in the latter 
in favor of his polypharmacy. His studies in 
anatomy and physiology were done on animals 
and his incorrect observations as applied to 
the human subject remained authoritative for 
centuries during the next 1500 years. 

During the Greek, the Greco-Roman and 
the Alexandrian, as well as in the Nestorian 
' and the Arabian periods, both medical and 
surgical training were based essentially on the 
'apprenticeship system. This had certain ad- 
vantages, in that the apprentice followed the 
'master in his daily dealings with his patients, 
(^learned first hand by close observation, and, if 
; ,the master was interested in teaching, by in- 
struction. But it was faulty in that the ap- 
prentice saw the methods and learned the 
philosophy of one man only, and apprenticeship 
^ made him a copier, devoid of the knowledge of 
I'other teachers, and discouraged independent 
^'thinking or the spirit of research, because of 
^imposed authority. So imbued with tradition 
^and the implicit authority of men like Galen 
^were the doctors of the Middle Ages that 
'krely did an original thinker, like Hugo, Theo- 
‘doric and Henri, dare to question the didactic 
teachings of their predecessors. 

^ After Galen and Soranus, both great figures 
m the Greco-Roman period (the latter was the 
jirst contributor to the knowledge of the dis- 
tees^ot^ the long night of the Dark 
^ges began. Notwithstanding the industry of 
;uch Byzantine compilers as Oribasius and 
ifaul of Egina, whose work did not reach Eu- 

i >pe until later, medicine and surgery became 
jparated and both sank into deep desuetude, 
he disruption of the Roman Empire, the 
egradation of its morals and morale and the 


invasion of the wild barbarians o( tlic nort 
resulted in near oblivion of arts and scicmccs 

The steady spread of Christianit\ and it 
final acceptance by Constantine introduced : 
new attitude toward suffering and tlisease ii 
the remnants of the Roman laupirc. The crime 
and immorality of the later Romans and the in- 
vading northern hordes dro\'e man\ ol the 
Christians into asceticism, and initiated the 
founding of monastic orders and their monas- 
teries. I'he belief that disease and dih)rmily 
were Heaven .sent, to be accepted in humility, 
as well as the worsened poly[dvarmae\ ol‘ (ialen, 
with its plague of nauseating drugs and filthy 
ingredients which only added to the misery of 
the sick, led to iJicantations and prayc‘rs for 
the treatment of the sick, and, as medical art 
grew empty, sorcery, demonology and astrology 
added to the confusion. 

As the monasteries increased, many (d tliem 
established hostels for the sick and maimed, 
where the religious ministrations of the monks 
w^erc provided them. As time went on, du* mom 
astic orders imposed certain defining regula- 
tions on those taking orders- three of them 
striking in nature; the long woolen cassock, the 
tonsure and the prohil)ition of the heard* Tlte 
latter two required the regular shttving of the 
monks by the barbers who becanK‘ attached to 
the monasteries. A later edict n‘quiring the 
blood-letting of every monk five times a year 
increased the work of’ the l)arl)ers and their 
association with blood. 

This all inevitably led to the transfer of imy 
surgical procedure to the barbers, who later 
came to be known as barber-surgeons. add 
to the divorce of medicine from surgery and 
to the insistence that therapy for any illness 
not requiring surgery be limited in Icmg retbed 
cleric physicians, came the famous, infamoiiH 
Papal Edict of the Council of 'Tours in 1 KA, 
which read “Ecclcsia abhorret a sanguine'* (i\w 
Church shuns blood). Thus was medicine cut 
off from its more effective and definite form 
of therapy, surgery, which scf^aration hmed 
until the nineteenth century. In IhiglaiKl Ii) 
this day the physician is called Doctor, the 
surgeon, Mister. 

Meanwhile, how did Greek medicine and 
philosophy survive to be reintroduced and re 
juvenated into Italy and Europe through 
the medium of Arabic ra,anuscripts? During 
the fourth century a small Christian sect in 
Mesopotamia, known as the Nestorians, be» 
came involved in religious controversy. In their 



15 


Training of the Surgeon 


desire to get at authentic Biblical sources, they 
turned to the Greek Septuagint version of the 
Bible. In doing so the Nestorian scholars be- 
came conversant with the Greek language, and 
thus became acquainted with the manuscripts 
of Greek medicine and philosophy in the 
Alexandrian School and translated them into 
their own Syriac language. This led to their 
establishing a school and hospital in their city 
of Edessa. With the decline of the school in 
Alexandria the Greek sources of medicine and 
science remained with the Nestorians. 

Because of the heresy of the Nestorians in 
their tenet that the Virgin Mary was the 
Mother of Christ, but not the Mother of God, 
they were expelled from Edessa by the Catholic 
Church in 489 a.d. and were given asylum in 
Gondisapor, a Sassanian town in southwestern 
Persia. Here they re-established their medical 
school and hospital. They translated their 
Syriac texts of Greek medicine and philosophy 
into Arabic, and for the next 200 years were 
the repository of hippocratic and galenic medi- 
cine. The nascent Arabs, after conquering the 
Near and Middle East, sought the services of 
the Nestorian School and Hospital and were 
tolerant of these Christians because of their 
views of the Virgin Mary not being the 
Mother of God. 

The Nestorian scholars with their transla- 
tions of Greek manuscripts into Arabic assisted 
the Arabs in establishing medical schools and 
hospitals in Baghdad, Damascus and Cairo. 
The Mohammedan conquerors of North Africa 
and Spain carried Arabic medicine with them, 
and in Cordova in Spain they established a 
medical school which did not delegate surgery 
to menial barbers but produced Arabic and 
Jewish physicians who practiced surgery as 
well as medicine. Both medicine and surgery 
in the Nestorian, Arabic and Cordovan schools 
were taught by the apprenticeship method, 
and in certain of the well-organized hospitals 
bedside teaching was conducted, especially in 
the Nestorian hospital in Gondisapor. 

Until the eleventh century monastic medi- 
cine, as practiced by the monks and clerics, 
consisted in the cult of faith healing, an im- 
plicit belief in the miraculous power of the 
saints and their holy relics. Supernatural help 
came to be accepted because of the failure of 
medical art in sickness, especially in the great 
epidemics. In the eleventh century was estab- 
lished the first independent medical school in 
Italy, in the town of Salerno near Naples. 


Monastic, Jewish, Arabic and Greek influences 
led to the tradition that the school was founded 
by the Four Masters. To the Salernitan center 
came the Garthaginian scholar, Constantinus 
Africanus. He had learned Arabic and had 
traveled extensively. In Salerno and in the 
cloisters of Monte Casino, he translated into 
Latin, from Arabic texts, works of Hippocrates 
and Galen and the Cordovan physicians. In 
this way Arabic medical doctrine was intro- 
duced into Italy and France and profoundly 
influenced medical teaching in these coun- 
tries as late as the seventeenth century. It did 
great harm to surgery in the advocacy of the 
cautery and of laudable pus in the treatment 
of wounds. 

The establishment of universities began in 
the twelfth century— Paris (HOO), Bologna 
(1158), Oxford (1167) and Padua (1222), 
followed by many others. But at first these in- 
stitutions were under the direction and influ- 
ence of the Church, and therefore the medical 
students were under servile obedience to dog- 
matic authority and were forbidden to give any 
treatment with the hands. The fundamental 
error of medieval medicine was in its divorce 
of medicine from surgery. 

In the following century, however, a few 
independent spirits appeared as physicians who 
did not hesitate to question authority, in- 
veighed against the suppurative treatment of 
wounds and preached the doctrine of primary 
union. Among these were Hugo, Theodoric 
and Henri. 

In 1260 Jean Petard founded the College de 
Saint Come in Paris, for the purpose of dis- 
tinguishing the lay surgeons, wearing long 
robes, from the short-robed barber-surgeons, il- 
literate in Latin. The fact that the lay surgeons 
were permitted to marry as compared to the 
long-rohed physicians, who were clerics, was 
an asset, but more important was the fact that 
the famous French surgeon, Lanfranchi, was 
the leading light in the college at the time. 
Increased entrance requirements, including; 
two years of the study of medicine and phrii, 
losophy in Latin, were followed by two years 
of surgery before becoming a lay surgeon o| 
the long robe, with the title of Maitre Chr 
Turgien Jur6. | 

However, the persistent opposition of thl 
physicians and the failure of the College t| 
recognize Amhioise Pax6 lost them the leadei 
ship of French surgery. Furthermore, they stil 
advocated the use of the cautery and suppur| 



16 Chapter L History of Surgery 


tion, for they followed the teachings of Guy 
de Ghauliac. The surgical teaching was by ap- 
prenticeship under the dialectic teachers of the 
College. It was replaced in 1723 by the Acade- 
mic Chirurgique de Paris. 

Menaissance Surgery. Freedom of thought 
and the escape from dialectic authority came 
to Europe in the fifteenth century as the re- 
sult of several factors: the navigational ex- 
ploits and the discovery of the Americas; the 
fall of Constantinople, with the escape of By- 
zantine scholars with their Greek and Arabic 
manuscripts into Sicily and Italy; the inven- 
tion of gunpowder; and, most important of all, 
the invention of printing, which made possible 
in great amount at a rapid rate the reproduction 
of the texts of ancient and contemporary 
scholars. 

In the influence of freedom of thought on 
surgery, the greatest factor was the introduction 
of dissection in Padua, Bologna and Florence. 
Equally significant was the effect on the artists 
portrayal of the human form, which resulted 
in the transition from the primitive to the 
normal painting of the figure. An interesting 
story is told of the common meeting ground 
of the physicians and the artists in an apothe- 
cary shop in Florence, where the former came 
to have their prescriptions filled, the latter to 
buy their pigments. When it became known that 
the physicians were having dissections, their 
artist friends were given permission to observe 
the dissections, at times crowding out the doc- 
tors around the dissecting table. 

Undoubtedly Leonardo da Vinci, the first 
great anatomist of the period, who was then 
living in Florence, was one of the first artists 
to join the doctors in the dissections. He is 
said to have made 750 anatomic sketches from 
the dissecting table. He may justly be called 
the father of modern anatomy, although Vesa- 
lius, fifty years later, in his epoch-making 
Fahrica had a far greater influence on surgery 
because of Leonardo’s failure to publish his 
anatomic studies, many of which were not dis- 
covered until they were found in the Royal 
Library in Windsor Castle in 1784. 

Vesalius with his Fahrica had a profound in- 
fluence on surgery, as did Harvey with his 
De Motu Cordis, published in 1628, describ- 
ing the circulation of the blood. For these two 
great works freed the surgeons from the ban 
^f galenic doctrines which had misled them for 
centuries. Increased knowledge of anatomy 
Juid reGuirent wars on the continent and Eng- 


land, with the introduction oi’ gunpowder, re- 
sulting in a particular type ol' wouad, in- 
creased the standing oF the surgeons and the 
demand for their services. I liis was es{)t‘cially 
illustrated in the career {)f Ainbroisc Pare, the 
great military surgeon oi the sixteenth cen- 
tury, which has been described. 

During the sixteenth and the swenteenth 
centuries, the training oF the surgeon in the 
hospitals and in the armies continued to he 
by the apprentice method. I lie lack of anes 
thesia and asepsis Favored speed as the sine 
qua non For the benefit of both patient and 
surgeon. Little elective surgery was clone. Such 
procedures as herniotomy and lith(aom\' uwv 
still delegated to a Few specialists, wlui kcf>t 
their techniques secret as well as their wliere 
ahouts aFter they had operated ( hence their 
name '‘fugitive surgeons”), 'riuxse so ealkxl 
“specialists” had too high a mortality to have 
permanent offices. 

Most of the surgery clone hy the regular 
surgeons in the h()S{)ita!s of Europe and Great 
Britain was of an emergency and traumatic na- 
ture. Compound fractures demanded ani{)uta 
tion of the limbs involved, and even leister, 
before he developed his antiseptic techni(|iie.s, 
had a 45 per cent mortality in his am put a 
tions. 

An increasing knowledge oF tmatomy and 
the recognition of its importance in surgical 
training resulted in the surgeon teaelting tlu' 
subject. All the great surgeons of the eonti 
nent and Groat Britain during the eighteenth 
and the early part of tlie nineteenth t*enturies 
had preceded their work in surgery as teachers 
of anatomy, and many of them amtinued to 
go from the dissecting room to their o|H*ralions 
in the hospital without change of clothes or 
cleansing of their hands. 

France, In France the Revolution played 
an important role~at first very detrimental /for 
all the medical faculties were td)o!ished because 
of their royal affiliations. But the wars in liu 
rope which followed made surgical tniining 
mandatory, and the National Convention e.s 
tablished what were essentially military inedi 
cal schools in Paris, Montixd'licr md Stniss- 
bourg, Napoleon later organized the Paris 
School of Medicine, and in 1806 he incorpO" 
rated the medical school into the Llniversity 
of Paris as the medical branch of the institu- 
tion. When medical education was again re- 
organized in 1830, there was started the system 
of the Concours by which the candidates for 



17 


Training of the Surgeon 


medical and surgical appointments competed 
against each other by taking oral examinations 
before elected examining bodies. 

During the first half of the nineteenth cen- 
tury, surgeons appeared in France famous for 
their knowledge of anatomy and their surgical 
skill. Special mention should be made of Larey 
(1760-1842), the leading military surgeon 
under Napoleon, one of his accomplishments 
being the organization of the famous ambu- 
lances to rescue and treat wounded soldiers; 
of Dupuytren (1778-1835), who became the 
Head of the Department of Anatomy in the 
Paris Academy of Medicine at the age of 23, 
and Surgeon-in-Chief at the Hotel Dieu when 
he was 38. Although hated by all his colleagues 
because of his haughty bearing and disdain for 
the work of other surgeons, he was acknowl- 
edged the greatest surgeon of his day. Lembert, 
Dupuytrens pupil, devised the intestinal su- 
ture which insured the outer approximation 
of serosa to serosa, and laid the foundation 
for all modern gastric and intestinal surgery. 
Velpeau, Malgaigne and Nekton should also 
be included among the prominent surgeons of 
this period. 

Great Britain. In the early part of the 
eighteenth century little, if any, systematized 
instruction in surgery was to be found. Ap- 
prenticeship with a practicing surgeon was the 
only available method. At St. Thomas’ Hos- 
pital in London, William Cheselden (1688- 
1752), then the leading surgeon in that city, 
began lecturing in anatomy and surgery, and 
in 1763 Percival Pott (1714-1788) began a 
series of lectures in surgery at St. Bartholo- 
mew’s. In 1769 the Medical School of Guy’s 
Hospital was started, and soon after united with 
the school in St. Thomas’ Hospital. Surgical 
lectures were given there and medical lectures 
at Guy’s Hospital. 

In Scotland a medical school was organized 
in Edinburgh by John Munro, His son, Alex- 
ander Munro (1697-1767), started the famous 
School of Anatomy in Edinburgh. He was suc- 
ceeded by his son and grandson, so that this 
Chair of Anatomy was held by the Munros for 
140 years. 

The most famous of British surgeons of this 
period was John Hunter (1728-1793), who 
ranks with Pard’and Lister as one of the three 
most influential surgeons of all time, and as 
the founder of experimental surgery and ex- 
perimental pathology. He was a man of un- 
bounded energy, insatiable curiosity, and a de- 


termination to know the why and the how of 
surgical lesions as well as natural phenomena. 
As an uncouth youth he was brought to Lon- 
don from his home in Scotland by his older 
brother, William, then famous for his School 
of Anatomy in Windmill Street. John became 
fascinated with the study of anatomy which 
later culminated in the Hunterian Museum of 
some 13,000 biologic specimens, most of them 
prepared by him and many of them still to he 
seen in the Royal College of Surgeons in 
London. 

John Hunter studied surgery with Chesel- 
den and Pott, and later was appointed Sur- 
geon to St. George’s Hospital. He developed 
surgical pathology into a live and essential 
discipline. His studies in inflammation, shock, 
syphilis and teeth were unique. But his most 
outstanding contribution was in the pathology 
and treatment of aneurysm. From an experi- 
ment which he performed by tying the external 
carotid artery of a deer, he found that the 
growing antler on the side of the ligated ar- 
tery, which at first had turned cold, later re- 
gained its warmth and continued to grow. 
When he had autopsied the buck he found 
the ligature secure, but saw that the blood 
supply to the antler was by way of small col- 
lateral arteries. ‘‘Oho,” he said in his notes, 
“I see that under the stimulus of necessity the 
smaller arterial channels greatly increase in 
size to do the work of the larger. I must re- 
member that.” This he did, for he changed 
the old Greek Antyllus operation of ligating 
the artery above and below the aneurysm to 
the technique of ligating the artery well above 
the aneurysm and hy-passing the sac, with 
the development of compensatory collateral 
vessels. 

Hunter was forever observing and experi- 
menting. He commanded his pupil, Jenner. 
of vaccination fame, who was about to make a 
journey to the Near East, to bring him a fetus 
of the camel in each of the eleven months ol 
gestation. It is not recorded by what means 
he secured the intact skeleton of the famous 
Irish giant. He became the greatest teacher ii 
anatomy and surgery and had many famou 
surgeons among his pupils from Great Bril 
ain, Europe and America. England hecam 
the surgical center of the world in 1800, owin 
to the great surgeons who had trained und( 
John Hunter. Among them were Ahernatk 
Cline, Astley Cooper, Physic, and the phys 
cian, Jenner. 



18 


Chapter L History of Surgery 


Astley Cooper succeeded Hunter and Aber- 
nathy as the leading surgeon in London in 
ability and practice. He contributed soundly to 
anatomy and surgery. In 1804 he published a 
beautifully illustrated monograph on hernia. 
In this monumental treatise, he described every 
known type of hernia, except one, that now is 
so common, the postoperative ventral incisional 
variety. 

In Scotland the most famous teachers of 
anatomy and surgery in the pre-listcrian era 
were Robert Liston (1799-1847), William Fcr- 
gusson (1808-1877) and James Syme (1799- 
1870), all three of Edinburgh. Liston was a 
giant physically and was the boldest and most 
rapid operator of his day. He was one of the 
first surgeons to use ether anesthesia, but only 
in the last year of his life. Fergusson was a 
great anatomist and surgeon. His dissections 
were superb, and the surgical instruments he 
devised are still in use today. Syme began his 
work in anatomy and later became Surgeon 
to the Royal Infirmary in Edinburgh, where 
he trained Lister and gave him every opportu- 
. nity to carry on his researches in inflammation. 

The lecture system was the accepted method 
I of surgical teaching. The lectures were given, 
i as has been stated, by leading surgeons in the 
I ; lecture halls of hospitals. But the instruction 
- jin anatomy in both England and Scotland, at 
J . this time, was given in private schools of 
I anatomy. The failure of city authorities to per- 
^mit the dissection of unclaimed bodies of in- 
•. mates of hospitals and asylums resulted in 
grave robbery to provide cadavers for the 
schools of anatomy. Rival teams of grave rob- 
jj-bers, called Resurrectionists, vied with each 
ijg other to supply dissecting material for the sur- 
geons teaching anatomy. Indeed, some of the 
^|.]medical students attending the anatomy classes 
gjCngaged in the hazardous business. 

[jq In the “Diary of a Surgeon in the Year 
1751-1752,'' John Knyveton, a medical stu- 
i^dent in Dr. Urquehart's School of Anatomy, 
y^had this to say about his part in body snatch- 
ling: 

j Nov. 7. Vastly tired this morning as the re- 
q^sult of a Hazardous Escapade from which I 
P)Count myself lucky to have escaped without 
)y^Giievous Harm to Life and Limb. Mr. Bloom- 
g^eld did yester eve put to me that we should 
^jfdisinter the body of the hanged woman for the 
^^Advancement of Our Art and the Glory of 
after some talk I agreed and 
; we approached our worthy teacher who warn- 


ing us of the Dangers- for hanging is not th 
least penalty, one is likely to he torn to piecci 
by the mob should the}' learn of it did then 
commend our Diligence and whilst saying that 
he would ha\x’ no hand in it and would know 
nothing of it should it come to light, did call 
his huge manseiwant to him and gate in- 
structions that he was to help us. So home to 
an early supper . . . and so to Dr. Ur(|iie-' 
harts to enter it by the small gate to find that 
the Doctor had gone out hut his man and 
Mr. Bloomfield and Messrs. Pope and Sinclair 
gathered in the Anatomy room \a’r\ ecnnlVirt 
able before a fire smoking and iliseiissing a 
flask of w'ine. So with them to pass the t‘ve- 
ning in pleasant discourse. 1 grow ing somew hat 
drunken the wine, very potent, and wheii the 
clocks had struck the half after twelve tn tnlleei 
spades and grapples and to mullle ourst'lves 
in thick cloaks. . . . And so into the lane and 
to the graveyard where Mr. Pofie did fleleh 
so loud this causing Dr. Unpiehart s man to 
swear vilely vowing that he would ratbt‘r have 
a School of Apes to help him than such turnip 
heads. I'he grave not easy to find then* being 
very many in a small place aiul ihv niottn did 
come out from behind the clouds which I did 
not care for as we were more likely to si’tm 
but with its aid to find u'here t!ic mould had 
been newly turned. George Blumenfiek! very 
vehement to dig up the coflin only to find this 
being opened did prove to coiuaitt an old 
woman very foul Then Mr, Sinclair m siltiirg 
down did find the ground give way himeatli 
him and so we found the hanged wench aiul 
dragged her out and put in tlte sack whieli Mr. 
Pope and I did then carry between us and 
with great haste to the lane and so to the Doc 
tors again, all mired and sweaty, (ieorge Bloom 
enfield did brew us a bowl of puneft and wv in 
need of such a Specific, Lord, what a business 
this be, this Quickening of the Aweful Dead, 
at night when the powers of evil lx* uhrcjad, 
amongst the tombs and the earth ant! ihv 
dreadful worms! Fit werrk only for men of 
Brutish Minds! Did resolve then to have no 
more of it, but on reflection reali/.e that notlc 
ing is gained without labor and so as i\!cdi 
cine be the most noble of the Arts so the Gate^ 
way to it is corresi^ndingly difficult and ardu 
ous to pass. Slept on a couch at the Doctors, 
and to home this morning at Mr. I lunt s and 
with him and Mrs. Hunt to church, where I 
heard a tolerable sermon aptly enough on the 
Resurrection, and wonder what his Reverence 



19 


Training of the Surgeon 


would say of my night s activities. Shall to bed 
early this night.'' 

In Edinburgh, in 1827, the town went mad 
over the discovery that two of the grave rob- 
bers supplying Dr. Knox’s School of Anatomy 
had murdered a number of people, by smother- 
ing them, and selling them as freshly exhumed 
bodies to the School. In London, in 1831, two 
grave robbers were arrested. It developed that 
they had murdered thirty to sixty people by giv- 
ing them rum and laudanum and had sold their 
bodies for dissection. Both were convicted and 
publicly hanged. Parliament then passed a bill 
regulating the supply of unclaimed bodies “for 
purposes of anatomizing." Grave robbery thus 
came to an end. 

During this period of the Resurrectionists, 
the surgeons and the medical students came 
from the dissecting rooms to the hospitals to 
take part in the operations and deliveries. An- 
tiseptic precautions were unknown and the 
varying states of putrefaction of the cadavers, 
together with the failure to change clothes 
and wash hands, made hospital infections an 
unbelievable nightmare. In some of these in- 
stitutions, the mortality reached 80 per cent of 
the surgical and obstetrical admissions. 

Germaay, The best known surgeons in 
Germany during this period were Conrad 
Langenbeck (1776-1851), von Graefe (1787- 
1840), Dieffenbach (1792-1847), Stromeyer 
(1804-1875) and Bernhard von Langenbeck 
(1810-1887), The elder Langenbeck was Pro- 
fessor of Anatomy and Surgery at Gottingen 
and Surgeon General of the Hanoverian Army. 
He belonged to the sleight of hand type of 
surgeon, and is said to have amputated a 
shoulder while a colleague present was taking 
a pinch of snuff! Von Graefe was the Professor 
of Surgery at the University of Berlin and is 
considered the founder of modern plastic sur- 
gery. Dieffenbach succeeded von Graefe. He 
was the first to cut the eye muscles for stra- 
bismus, and was one of the first to operate on 
vesicovaginal fistula. He was a cultured scholar 
as well as an able surgeon and teacher. 

Stromeyer was one of the founders of ortho- 
pedic surgery, and was considered the father of 
military surgery in Germany. He was a poet as 
well as a great surgeon. Bernhard von Langen- 
beck, the nephew of Conrad, became the great- 
est surgeon and clinical teacher of this period 
in Germany. Under his tutelage the most 
famous surgeons of the past fifty years in Ger- 
many appeared. Two of his greatest accomplish- 


ments were the founding of the German So- 
ciety of Surgery, and the editing of the great 
surgical journal of that day, the Langenbeck 
Archiv. 

Long-term training in surgery was started 
in Germany in a pattern of its own, and is 
continued to the present in much the same 
form. All students on graduating from the 
medical school are required to take a year of 
internship, most of them preferring the rotat- 
ing type. After that they can become assistants 
in surgical clinics, or, as at present, they may 
wait out a year as volunteers. This volunteer 
system is necessary in Germany at the present 
time because of the great demand and the rela- 
tively small supply of such positions. This as- 
sistantship is somewhat comparable to the 
assistant residency in the United States. The 
assistant can advance to the position of first 
assistant in four or five years, but few reach 
this promotion. After this, the first assistant 
may be promoted to become an Oberarzt, com- 
parable to the chief resident in our clinics. But 
unlike him he may serve in that capacity for 
a period of ten to fifteen years, waiting for 
an appointment as the head of one of the sur- 
gical clinics. In the meantime, he assists the 
professor who as the Geheimrat is the omnis- 
cient one, not to be questioned in any way, 
and who does practically all the operating. 

The same method of surgical training is fol- 
lowed in most of the European clinics as in 
Germany, with individual modifications in 
each country. 

America. Surgical training in the United 
States, until the latter part of the nineteenth 
century, was by apprenticeship. A few of the 
ambitious young surgeons of the period under 
discussion went to Paris, London and Edin- 
burgh for further training. Especially notable 
were Physic and Dorsey of Philadelphia who 
studied under John Hunter in London, and 
Valentine Mott of New York who worked with 
Astley Cooper and later became famous for his 
original work in vascular surgery. Ephraim- 
McDowell of Danville, Kentucky, studied 
under John Bell in Edinburgh. In 1809, he 
performed the first ovariotomy in abdominal 
surgery on a 47 year old woman, who hac] 
come to his office on horseback, a distance oi; 
21 miles. At the end of the ride she had d^‘ 
veloped a decubitus of the lower abdomen a? 
a result of the pressure of the pummel of th^ 
saddle. McDowell operated while a group o{ 
the citizens of Danville waited with loader 



20 


Chapter 1. History of Surgery 


guns to operate on him if the woman did not 
survive the ordeal. The woman not only sur- 
vived, hut lived to be 78, without any re- 
currence of her trouble. 

During the next hundred years, especially 
after the discovery of anesthesia, elective sur- 
gery increased. Attention was concentrated on 
the development of new techniques and new 
instruments. In the late 1870 s and early 1880 s, 
the treatment of abdominal acute infections 
was initiated by the attack on appendiceal 
abscess— then called, perityphlitis. Surgery of 
the gallbladder, the stomach and the intestinal 
tract was beginning. The radical attack on can- 
cer was initiated by the radical mastectomy of 
Halsted and Willy Meyer, in 1880; Billroth, in 
Berlin, performed the first partial gastrectomy 
for cancer in 1880. 

In the medical schools of Harvard Univer- 
sity, Columbia University and the University 
of Pennsylvania, medicine and surgery were 
taught by the lecture system and little bedside 
teaching was given before 1890. In some of 
the schools, private quizzes to prepare men for 
, the competitive hospital examinations were 
attended far more regularly than the lectures 
1 in the medical schools, 
i Much of the surgical teaching during the 
1 latter part of the last and the early part of the 
: present century was given from the operating 
i .amphitheater, where the students saw backs 
' jand blood but got little worthwhile instruc- 
„ jtion. This led to showmanship on the part of 
•; the leading surgeons and a tendency to con- 
^j^tinue the emphasis on speed in operating, 
which, of course, appealed to the immature 
.j^and uncritical students. At this time there 
jgbegan a shift from the emphasis on anatomy to 
,j.the study of surgical pathology in preparation 
^|.for surgery. This was to be followed in the 
early years of the present century hy the em- 
ifphasis on physiology as the most important 
.j^of these three disciplines as the approach to 
original and constructive surgery, 
pi In or about 1880, listerism as well as the 
j^’ase of anesthesia had so increased the elective 
; juigery in the hospitals of the United States 
g;hat internship in surgery became well estab- 
lished. Before this time interns served for both 
ijj*nedicine and surgery. The surgical internships 
^^ere from twelve to sixteen months in most 
^^ospitals, with a period of four to six months 
;>f houseship, during which time the intern 
given operative work, the amount depend- 
ing upon the good will of the attending sur- 


geons with whom he had been uurking. In th 
larger centers like New \nrk CT\, the eenqx 
tition for appointment to the surgical service 
was determined largely hv the amount of opera 
tive work that was given to the hous(‘ surgeon 
This resulted in a \'idous eirele, h>r the hos- 
pitals desiring the host men I'roiii the medical 
schools gave an increasing aniouiu of opera- 
tive work to the relativel} intwpt'rienet'd in- 
tern, who, when he left the hosiatah went into 
general practice, doing little li any surgery 
thereafter, unless lie later heeaine attached to 
cl surgical service in one ol the hospitals. 

The change from this shorUenn aiul waste 
ful surgical training to the long term and sound 
rcsidencN' training was initiakal hy William S. 

I lalstcd. lie hacl studied in the IxM (Tnnan 
clinics before he returned Uj New York (at\, 
where for a period tif four years lu‘ was known 
as a brilliant young surgeon, imhued with the 
newer aseptic technitfucs. A most unlortunate, 
but entirely innocent, exficrience v\ilh the 
study of cocaine as an agent for puHlucing 
local and nerve block anesthesia resultt*d in his 
having to drop out of surgery for a period of 
four years. But this enforced withdrawal from 
surgical activity gave him time' for eontem 
plation and a reappraisal of Ids ideas ol* stir 
gical tcclmiqucs and of surgical training. Wil 
liam H. Welch, his great friend wlm rescued 
him from his innocently uct{uired adtlietion, 
and who appreciated his great promise as a sur 
gcon, took him to Baltimore t<i lie his co- 
worker in the newly organr/.ed Johns ! lopkins 
Medical School. Welch had been tlie pathol- 
ogist at the Bellevue 1 fospital in New Y(jrk 
before he was chosen to he detm ol* llie new 
school in Baltimore. 

Halsted hacl seen and appreciated tlie ad 
vantages of the long-term trainirig in the CSer* 
man clinics, hut also was aware of thdr hiilure 
to give this training to nrore <iiialilietl young 
surgeons. When he was chosen to take dwrge 
of the surgical service at Johns licqddns in 
1889, he appointed residents from t|iialificd sur- 
gical interns, who served from four to six 
years, with the appointment to the chief resi- 
dency for a period of one or more years. This 
resulted in such well-trained surgeons, after 
such wide experience in operative and experi- 
mental surgery, that his residents were ap- 
pointed to chairs of surgery in the medical 
schools of the country. 

However, for many years the Halsted resi- 
dency program was not favorably received 



21 


Training of 

the surgical clinics of the country because of 
the antagonism of the younger attendings and 
the surgical interns, who feared that the resi- 
dency system would deprive them of the opera- 
tive experience which they had been having 
in the hospitals where the short-term training 
had prevailed. It was not until the 1920's, 
when the necessity for long-term training be- 
came mandatory, because of the advantages to 
the patients and to the attending staff in the 
surgical clinics, that residencies were started 
and soon became the recognized and sound 
method of training those who wished to pre- 
pare for major and radical surgery. 

Another change in the policy of surgical 
teaching in the undergraduate curriculum in 
the medical schools was the recognition of the 
fact that training in the operative techniques 
is a graduate function that has to be done 
in the hospitals in the surgical internship and 
residency periods, Teaching the symptoms and 
signs of lesions requiring surgery was em- 
phasized rather than the techniques of treat- 
ing them and replaced the lectures which for- 
merly were given in the courses in the surgical 
specialties. With the crowded curriculum in 
the medical schools this was essential and 
sound. 

This establishment of residency training in 
the university surgical clinics in the United 
States may be justly considered the greatest 
advance in surgical training in the history of 
surgery. For as it is now done in these, and the 
best municipal hospitals of the country, the 
residents are given the finest operative train- 
ing, and in their last year independent opera- 
tive work. They are given increasing responsi- 
bility, as they advance in their residencies, for 
the conduct of the surgical services. This makes 
them far more experienced in assisting the at- 
tending surgeons as well as in the care of the 
patients, for they live in the hospital and are 
on call at all times to prevent complications, 
or to treat them promptly if they should occur. 
Under this system patients get far more in- 
telligent and constant care than was the case 
in the old days. Furthermore, under this plan 
far more surgeons receive adequate training 
and experience than is the case in European 
clinics, and are given the opportunity of inde- 
pendent thinking without the domination and 
dictation of the omniscient Geheimrat. 

So able and proficient did this young gen- 
eration of long-term trained residents become, 
that it became obvious to the leading surgeons 


the Surgeon 

of the country that these surgeons should be 
given recognition. Previously, qualifying boards 
in other specialties had been organized under 
the American Medical Association. In 1937, at 
the instigation of the American Surgical Asso- 
ciation, the Qualifying Board in General Sur- 
gery was organized and began giving written 
and oral examinations to surgeons who had 
completed their long-term residency training. 

If these surgeons passed the examinations, they 
were given certificates of proficiency, with the 
understanding that they would limit their 
work to general surgery. 

So outstanding was the ability of these quali- 
fied surgeons during World War II, as com- 
pared to the work of the medical officers with 
short-term intern training, that the young of- 
ficers who had had only nine months of intern- 
ship were convinced that residency training 
was essential for any man going into surgery. 
This conviction was strengthened when the 
Veterans Administration, properly reorganized 
after the war, required such residency training 
for appointment to the position of attending 
surgeon in the Veterans Hospitals. 

Other developments in the surgical field in 
this country have added greatly to the educa- 
tion and training of the surgeon. The surgical 
journals that have been published have become 
increasingly competent in publishing the orig- 
inal studies of the surgeons, and in eliminat- 
ing much of the useless, repetitious and un- 
critical compilation of clinical material which 
in the past filled the pages of the journals. 

The annual and semiannual meetings of the 
national surgical associations and small travel 
clubs provide the very valuable means for our 
surgeons to see and to hear reports of the 
work of leading surgical authorities. This is 
especially true of the meetings of the Congress 
of the American College of Surgeons, with , 
the presentation of papers and the panel dis- , 
cussions, as well as exhibits of laboratory and 
technical procedures. This is also true of the 
Surgical Section Meetings of the Annual Meet- li* 
ings of the American Medical Association. Ex- ^ 
amples of how effective surgical journals and' 
meetings have been may be cited in the aston- 
ishing advances which have been made in the , 
field of thoracic and cardiovascular surgery, | 
and the spread of the information regarding! 
the techniques of these procedures throughout J 
the clinics of this country. Within a period! 
of two or three years, the new methods have ' 
come into use in all the leading surgical clinics. 



22 


Chapter L History of Surgery 


One of the most important results of the 
residency training program, together with the 
qualification of the residents who pass the ex- 
aminations of the qualifying board, is the 
recognition by hospital boards of managers, 
and now the public, that surgery should be 
done by properly trained and experienced 
men. This has made a great difference in the 
caliber of the surgeons appointed to hospital 
staffs throughout the country. 

In closing, we must revert to the historical re- 
lations of medicine and surgery, and say a word 
about its present phase. It will be recalled that 
the divorce of these two forms of therapy in the 
Middle Ages resulted in chaos to botL In the 
present era, although practiced by different 
groups, the two are so closely related that they 
cannot be separated as in the past. In our 
medical schools the etiology, pathology and 
diagnosis of disease are studied by all the stu- 


dents, as well as the indications for the proper 
therapy. Many of these diseases rcc|uire nicdical 
therapy in some stages of their development, 
surgery in others. 

The close association of the uHalic'al and 
surgical services in our liosjdtals toda\ , micl 
the fact that many of tire interns in these 
hospitals serve on both ser\T’es, bf*eak down 
any of the old Irarriers lx, ‘tween tltesc.' two 
disciplines. In many of the courses on the so- 
called “middle ground” diseases, teachers from 
both departments take {xirt, and tlu‘ teamwork 
of both groups in the comlxned clinics on 
many of these syndromes, and in t!u‘ folk iw- up 
of them, makes the physicians and the surgeons 
speak the same language, and tluax* are no 
miracles among friends. 

It is now an accepted fact that internal medi- 
cine and surgery are l)ut iwa brandies of ther- 
apy in the science of medicine. 



2 


Physiology of Wound Healing 


By WILLIAM A. ALTEMEIER, M.D., and JEAN M. STEVENSON, M.D. 


William Arthur Altemeier, a Cincinnatian hy birth, is a product of his home 
city's educational institutions. He has progressed through the ranks of the department 
of surgery of the University of Cincinnati College of Medicine to become professor 
and chairman of the department. He was director of the surgical hacteriologic laboratory 
and his interests extended to the detailed study of tissue healing. His contributioi'is to 
surgical literature have been fundamental. 


Jean Moorhead Stevenson, also an Ohioan, was educated in medicine and trained 
In surgery at the University of Cincinnati. His interest in the healing of wounds was 
stimulated by the late Mont Raid. 


Wound healing is an inherent physiologic 
process of animals for the repair of their in- 
jured tissues. A knowledge of the mechanism 
of wound healing and of the local and genera] 
factors which affect it is obviously essential. 
Unfortunately, this process is not the same for 
all tissues. Highly specialized tissues, such as 
those of the kidney and brain, repair injuries to 
themselves by the formation of granulation 
tissue and ultimate replacement by scar tissue. 
Less specialized tissues may be regenerated in 
a form almost identical with their normal struc- 
ture. 

A wound is generally defined as the solution, 
or break in continuity, of tissue resulting from 
mechanical force. Mechanical force denotes the 
characteristic of motion of the object which 
produces the wound. Thermal, bacterial and 
chemical agents axe also capable of producing 
wounds, but the character of the injuries pro- 
duced and the policies of management and re- 
pair are so different that they demand separate 
consideration. 

Wounds may he external or internal, obvious 
or obscure. Any tissue in the body may be in- 
volved in a wound while the skin itself may 
remain intact. This concept of a wound is fre- 
quently overlooked by those who generally con- 


sider wounds to he external manifestations of 
injuries. The student finds it difficult to ex- 
amine carefully a patient for an explanation of 
his complaints when there is no evidence of ex- 
ternal blood loss, or gross distortion of contour 
resulting from major breaks in the skeleton. He 
must be on his guard so as not to miss deep in- 
juries such as rupture of the spleen, liver, 
bladder or kidney; a torn hollow viscus; mesen- 
teric hemorrhage; retroperitoneal bleeding from 
multiple fractures; damage to great vessels; con- 
tusions of the heart and lungs; or injuries to 
the cerebrum and cord. 

Delays in diagnosis and treatment may lead 
to disaster. The newspapers’ term, “death from 
internal injuries,” carries with it an air of help- 
less, or hopeless, mystery which draws from the 
reader an expression of forgiveness. When the 
victim of an accident reaches the emergency 
room, it is regrettable and shameful if every 
effort, including surgical exploration, is not 
made to determine the nature and extent of his 
injuries. 

Before considering the local physiologic 
changes within the wound, one should be 
familiar with the general physiologic effects 
fallowing surgical trauma or injury due partly 
to tissue damage, short-term starvation, immo- 


Page 23 



Chapter 2, Physiology of Wound H ceiling 


bilization of the wounded area, and endocrine 
changes. These are normal metabolic responses 
and are usually characterized by a temporary 
elevation of temperature and pulse rate, a loss 
of nitrogen from the body for three to seven 
days followed by positive nitrogen balance, and 
a loss of potassium for the first two to five days 
after injury followed by retention of potassium. 

A transient decrease in the excretion of urine 
occurs, and a diminished urinary excretion of 
sodium develops for two to five days after in- 
jury, followed by diuresis of sodium. A loss of 
weight occurs. Resumption of caloric and nitro- 
gen intake and a positive balance arc require- 
ments important to recovery. A drop in 
circulating eosinophils and an increase in the 
excretion of hormone products are the result of 
an accompanying endocrine readjustment be- 
tween the pituitary gland and the adrenal 
cortex. 

The histologists and pathologists have given 
us additional terms to help us in our under- 
standing of wound healing. If a wound is a 
break in the continuity of tissue, healing is the 
restoration of continuity of tissue. The factors 
which bring it about constitute a reaction to in- 
jury, and the whole process is called inflam- 
mation. 

The process of wound healing may be di- 
vided into three phases: initial or lag phase, 
the phase of fibroplasia, and the phase of con- 
traction of the scar. During the initial phase, 
the process of healing is initiated by the injury 
to the tissue cells, and it is essentially the same 
whether the injury is a planned operative pro- 
cedure or an accidential wound of violence. 

The force causing the injury may create a 
variety of changes in the tissues, sometimes 
dividing them as evenly as one could with a 
sharp scalpel, at other times completely tearing 
pieces of tissues away from the body, or leaving 
them hanging in shreds £ilong the edges of the 
wound. A How may only bruise the skin but 
mince the deeper fat and muscle, or fragment 
the underlying bone. A glancing blow may do 
little more than brush away the top layer of 
skin. When tissues are divided, the contraction 
of muscle and elastic fibers tends to widen the 
gap, and the continuity of the vascular systems 
for the blood and lymph is affected. Fluids 
escape through the breaks into the wounds 
cavity and to the surface, if a connection exists. 
The quantity and rate of blood loss is deter- 
mined by the number, character and sizes of 
the vessels injured; the nature of the hole in 


the vessel; the clotting [)ropcrtics of th(‘ blood 
the types of the tissues injured; (he activity ol 
the patient; and the patient's blood pR‘ssure. 

An effective clotting nieehanisni is essential 
to the preservation of life. If bleeding into a 
wound could be prevented, one would observe 
that lymph and serum would fill the wouiul 
with clot and serve the processes of healing 
equally as well as blood. Some ol' llie lluicl 
which collects in a fresh vvoiincl comes from 
lymph and scrum, but the material is always 
colored with red blood cells Irum damaged ves- 
sels or an old blood clot. Wffien the Iluid which 
has collected in closed wounds is aspiratetl re- 
peatedly with a needle and syringe, it will l)e- 
eome progressively clearer until it resembles 
pure lymph or plasma. 

When a wound becomes eoatt'd with coagu* 
lum, the blecxling stops, and further loss ul Huid 
will consist of ])lasma or lymph whost^ flow ta 
the surface is essential to the continued growth 
of the granulation tissue, ‘^llie coaguluin which 
forms on granulation tissue comes Irom the 
clotting of serum and lymph while tlu* plasma 
becomes a by-product of this reaction. 

The formation and retraction td' tlu' clot slop 
the bleeding, unless the force of the stream is 
too great. Completely di\’idetl \Tssels will con" 
tract and retract, favoring stoppage witlt clot, 
Partially divided vessels cannot retract, and the 
lacerated lumen is held open, pndonging 
hemorrhage or predis}X)sing to setamdar)' bleed 
ing. Severed capillaries retract and eomracl 
just like larger vessels. .In experimental studies, 
they have never been seen to clot, but they may 
open up and resume function untler more 
favorable conditions. 

A clot which retracts poorR is std’t and in 
efficient. Bleeding may recur in such wounds 
after displacement of the clot during dressing. 
A firmly retracted clot efficiently sto|>s t)leeding, 
supports the wounds edges, and gives tlie 
wound what little strength it has in the early 
hours or days of healing, llus clot also pnu 
vides better footing for the cellular invasion l>e 
ginning at the periphery of the wound 

Excessive bleeding and dotting are undesir- 
able and may become haxardt^tis. A large dot 
cannot move itself, and it has little resistance to 
bacterial action. Its organization delays wound 
healing, increases the inflammatory reaction, 
and leaves behind an abundance of trouble- 
some scar. In some instances, the clots center 
will become liquefied, or infected, before it can 
be organized and will then require removal by 



25 


Physiology of Wound Healing 


aspiration or incisional drainage. In sutured 
wounds, large clots may create pressure, favor 
tissue necrosis, separate wound edges, increase 
morbidity, or impair function. 

Another effect of injury is the stimulation of 
an increased blood flow to the area. The result- 
ant vasodilatation causes the skin to turn pink 
and produces an increase in local heat. This 
response is immediate and it continues through- 
out the healing of the wound. 

Immediately after trauma, the pn of the tis- 
sues at the site of injury is shifted toward the 
acid side. In the deeper tissues, a pH of approxi- 
mately 6.4 will develop and continue during a 
considerable period of the healing of the 
wound. This is believed to be one of the fac- 
tors which produces hyperemia, capillary perme- 
ability, and local swelling due to an increase of 
intracellular and extracellular fluids. The swell- 
ing which develops is related to the type and 
severity of the trauma, but all soft tissues do not 
respond similarly. Rather insignificant injuries 
about the eyes and lips produce much more 
swelling than do similar injuries of the trunk 
or extremities. 

Marked swelling delays the process of heal- 
ing because it restricts circulation, retards local 
metabolism, produces necrosis ?f_ cells, and 
favors ^bacterial^rQwJi. Mild localized swell- 
ing, however, is considered to be beneficial. 
Capillary permeability increases, the channels 
widen, the rate of flow decreases, and the 
leukocytic cellular elements collect along the 
capillary walls and make their ways through 
the walls into the tissues. Leukocytes, histio- 
cytes and macrophages arrive in the injured 
area to aid in the removal of debris and the 
defense against bacteria. The phagocytic cells, 
instead of circulating through the clot, appar- 
ently dissolve their way into it by enzymatic 
action. By phagocytic and enzymatic action, 
their work precedes the regenerative growth of 
tissue. 

The debris in closed wounds must be carried 
away by the circulation, while in open wounds 
much of it may escape to the surface in the 
form of an exudate or pus. Proteolytic enzymes 
dissolve dead cells either within or outside of 
the phagocytic cells. Sometimes, bacterial en- 
zymes also assist in this work, but help from 
bacteria is usually not appreciated because 
their enzymes may also work on living cells. 

■ Proliferation and migration of endothelial 
capillary buds into the blood clot begin early 
and can be seen microscopically on the second 


day. The fibrin trabeculae in the coagulated 
blood clot form early and contribute the frame- 
work for the subsequent ingrowth of capillaries 
and fibroblasts from the wound edges. The 
capillaries supply the nutrition and reserves for 
the reparative elements and carry away their 
by-products of metabolism and catabolism. 

The early producL.ai fibroplastic and* -endo- 
thelial cell growthjs called 
and thini^siie is essential to the healing of 
every wound. There is a tendency to disregard 
serious consideration of granulation tissue when 
it lies in a vertical plane between the edges of 
a sutured wound. The regeneration accounting 
for this tissue is exactly alike in open and closed 
wounds, hut the very name which was 
adopted to describe it was the result of observa- 
tions made in open flat wounds. The same vol- 
ume of granulation tissue in a closed, or con- 
cealed, wound can give rise to future complica- 
tions. 

The fibroblasts secrete and deposit in the 
granulation tissue a protein, collagen, which 
produces strength to the bond between the 
wound's surfaces. The old collagenous connec- 
tive tissue at the periphery of the wound be- 
comes swollen and fuses with the new col- 
lagenous tissue by continuity of cell growth 
and reformation of collagen fibrils. The deposi- 
tion of fibrils begins in the periphery of a 
wound, which may still contain clot and mani- 
fest phagocytic activity, but it does not occur 
in any portion of a wound containing debris or 
necrotic tissue. 

Clinical signs of the formation of granula- 
tion tissue may remain hidden in wounds filled 
with clot, but one can detect its presence 
about the fourth or fifth day in flat wounds 
containing little clot. Steadily, the granulat^n 
tissue spreads and thickens until it is no longer- 
possible to recognize the previously exposed tis- 
sues, such as muscle, fat or fascia. The granules, 
which characterize the tissue, represent the 
presence of especially robust capillaries near 
the surface which sponsor the volcano-like 
eruption of tufts of fibroblasts and leukocytes. 

As a membrane for a surface wound, ox as a 
retaining wall about an inflammatory process, 
granul^ia]a^.tissue is a great protective device. 
Although this \vas l®wri genera- 

tions, it was Billroth who pointed out its pro- 
tective qualities against bacteria and their 
toxins in 1865. Billroth demonstrated that signs 
of tissue destruction, or systemic toxicity, did 
not occur after the application of contaminants 



Chapter 2 . Physiology of Wound Healing 



Figure 1. Healing by secondary intention. Large 
deep granulating wound of arm covered with healthy 
granulation tissue. 


to the granulating surface of wounds when free 
drainage had been established. Students, there- 
fore, may question the necessity for strict ob- 
servance of aseptic technique in the manage- 
ment of granulating wounds, but the answer is 
easily found. 

Contaminants will grow on granulation tis- 
sue and can cause trouble. Pseudomonas aeru- 
ginosa^ usually nonpathogenic for man, has a 
voracious appetite for newly planted skin 
grafts. The proteolytic enzymes and other 
toxins of such bacteria as the hemolytic staph- 
ylococcus and the hemolytic streptococcus may 
be absorbed to produce signs of toxemia. These 
and other organisms are capable of surviving 
for years in the cicatrix of a wound which has 
long been covered by epithelium, and may be- 
come reactivated by another subsequent injury 
to the same area. It is wise to remember that 
some granulating wounds, which appear to be 
innocent, may harbor organisms potentially 
pathogenic for those who dress the wound, or 
patients near by with open wounds. 

It is not unusual in the change of dressings 
:overing wounds to find them sticking to the 
granulation tissue and to see the tissue bleed 
vith removal of the dressings. A temporary rise 
n the temperature curve may follow. 

If removal of the dressings is postponed, 
hey may become putrid and the patient may 
)ecom£_ toxic^ Retained moisture and proteo- 
ytic enzymes may macerate and even attack 
he surrounding normal skin. When the by- 
)roducts of cell growth and bacterial action 
annot escape, some of them are absorbed and 
an produce a systemic response approaching 
hat of an undrained wound. 

The wall of granulation tissue about an un- 
Irained abscess may keep the process localized, 
t does not, however, stop the ahsorption of 


toxic products from the abscess as long as it is 
under pressure, as is shown by the febrile rc- 
ponsc before and after the drainage of any 
abscess. 

Granulation tissue can pianide for the pa- 
tient other kinds of protection, often unnoticed 
and unappreciated. A coat of fibrin may reduce 
the sensitivity of the exposed surf aces of a fresh 
wound. Sensory nerc’cs grow into the granula- 
tions, but they do not reach tlie surface until 
approximately the second week, depending on . 
how the wound has been managed and whether 
or not clforts have liecn made to retard the de- 
posit of excess granulations. 

Another variety of protection oUered by 
granulation tissue is the preservation of vitality 
in tissues, such as nerves, tendons, bone, large 
blood vessels and cartilage. l'hes(‘ tissues are 
easily damaged or killed when continuously ex- 
posed to the drying effect of air, rc‘])catet! <lress- 
ings, or bacterial infection. Prcser\’ation of the 
protective clot, followed by its early organi/a*’ 
tion into granulation tissue, protects such spe- 
cial tissues and permits them to sur\'ive. 

Much valuable information can be obtained 
by observing and studying granulation tissuis. 
The use of the words healthy or unhealthy is 
more practical than employment of the terms 
normal or ahnormal Normal granulation tissue 
need not be the same as healthy granulatmn 
tissue. The granulation tissue normally found 
in a fiftecivyear-old leg ulcer would i>e most 
unsuitable for the support of a skin graft 
The desired healthy granulation tissue is a 
thin, firm, bright-red membrane with a finely 
granular surface which docs not hleecl easily 
and which has no offensive odor (Fig. 1). The 
fluid loss from its surface is minimal, and it 
should resemble a transudate rather than an 
exudate. No foreign or necrotic material shook 
be present in the wound, and the surroiincling 
tissues should show no signs of irritation. The 
growth of epithelium over its periplieral mar- 
gins is indicative of a healthy state which will 
support epithelial growth. Healthy granulation 
tissue may contain bacteria but will not show 
signs of acute infection. 

. Unhealthy granulation tissue, on the other 
hand, is usually pale or cyanotic, and wet and 
soft from edema (Fig. 2). Its friable surface 
bleeds easily. The surface is coarse and irregin 
lar, as a result of overgrowth of tissue in 
some areas and limitation in others. Excessive 
exudation, or pus, covers the surface, saturates 



Physiology of Wound Healing 27 



A B 


Figure 2. A, Recent wound with unhealthy and infected granulation tissue. Edematous granulations are 
friable, bleed easily, and are covered with bloody purulent exudate. B, Chronic infected granulation tissue which 
is exuberant, pale, friable, and covered with purulent exudate. From the surface of indolent granulations, large 
amounts of proteins and electrolytes may be lost through continuous exudation. The paleness of the granula- 
tion tissues is caused by marked anemia and the edema secondary to infection and hypoproteinemia. 


the dressings, or irritates the surrounding skin. 
The patient may show signs of toxicity in the 
form of fever, edema of the part, regional 
lymphadenitis, malaise, and irritability. Pain is 
frequently present, and the wound may have a 
•qiutrid odor. 

Unhealthy granulation tissue is prone to 
occur in old wounds in which the period of 
stimulation for healing has passed, in a densely 
scarred base, or in a chronic infection. Any 
ischemia resulting from scarring of the base or 
other causes produces gray, yellowish-pink or 
cyanotic granulations. They are hard and fixed 
from fibroblastic growth and the formation of 
cicatrix. The surrounding tissues are likewise 
Lard and scarred. Pigmentation of the neigh- 
boring skin is common. The wound is unusu- 
■ ally sensitive owing to nerve regeneration and 
I a lowered yn resulting from the stasis. Epitheli- 
^ zation and generation of new granulations are 
at a standstill. 

The aging process of granulation tissue is 
largely the function of the fibroblasts. They 
produce the homogeneous ectoplasm and fibrils 
which have attachments to the cell bodies. 
Their arrangement seems to be affected by the 
lines of stress, and their appearance, in increas- 
ing quantities, coincides with the initial and 
continued shrinkage of the wound. This is not 
readily detected in the week-old wound, hut 
the development of the collagenous fibrils im- 
parts to the wound a steadily increasing tensile 
strength for the ensuing several weeks. Because 


a wound shows no gain in tensile strength until 
about the sixth day after injury, the term, lag 
period, is applied to this interval in the healing 
of a wound. It must be remembered that only 
because the tissues have been teeming with ac- 
tivity, an increase in tensile strength is possible 
in such a short time. After the sixth day, the 
tensile strength increases rapidly. 

The end result of this process of fibroplasia 
is scar or cicatricial tissue which accounts for 
the tensile strength, hardening, and toughen- 
ing of the wound as well as for occasional un- 
desirable sequelae. 

Scar tissue, however, is seldom as resistant to 
tension as is normal tissue. When present in 
excess, it may become a point subject to ab- 
normal stretching or herniation. An excessive 
force may stretch the scar into a state of dis- 
ruption (Fig, 3). 

Whenever possible, the surgeon directs the 
process of healing along lines favoring the mini- 
mal amount of scar tissue. The formation and 
contraction of scar are great aids to the epitheli- 
zation of an open wound because they reduce 
the size of the area to be covered by epithelium. 
The surgeon who is unaware of the part which 
contraction of scar plays in wound healing will 
erroneously credit the dramatic change in size 
during the second and third weeks of healing 
to epithelial regeneration. This contraction 
takes place in a concentric manner, but the 
greatest potential for shrinkage is in its longest 
axis. Scar will first effect its contraction in a 


28 


Chapter 2. Physiology of Wound Healing 



Figure 3. Hypertrophic scar. The skin mark on 
the abdomen was created by an abdominal incision. 
Tissue tension widened the scar and stimulated a 
hypertrophic change. The process is regressing as 
shown by the transverse wrinkles. Abnormal tissue ten- 
sion produced a hernia for this patient. The fingers 
mark the edge of the fascial defect. 

line of least resistance and such areas may be 
the last to show softening and relaxation. Ex- 
amples of these are readily found about the 
eyelids, lips, neck and flexor surface of joints. 

Fibroplasia may also cause an increase in 
tensile strength of the wound and shorten the 
period of morbidity. Tests on experimental ani- 
mals have shown that healed sutured wounds 
of the enteric tract may be stronger than the 
normal tissue. Specimens inflated with air often 
burst at a point removed from the site of in- 
jury. 

Unfortunately, the contraction of scar is a 
powerful force which can abnormally produce 
distortions and contractures (Fig. 4). There is 
little elasticity in scar tissue. If moderate trac- 
tion is maintained for a long period of time, 
contracture can be improved; but when the pull 
is discontinued, there is a gradual and definite 
return to the original contracture. Excessive 
force suddenly exerted upon a scar may disrupt 
it. 

Other effects of scar contracture include a 
squeezing effect upon all of the elements within 
the wound. The edema begins to recede. The 
capillaries become compressed and may be 
gradually obliterated, resulting in fading of the 
redness of the wound area. The tissues become 
stiff and hard. In large deposits of granulation 
tissue, cicatrization continues over many 
months; the final conversion of red scars into 
characteristically white ones may require a year 
I or more. 

I Although the tensile strength of a wound 
may be adequate for the resumption of func- 
tion in two, three or four weeks, depending on 
the location and t^ of tissue injured, its 
jactual strength continues to increase during the 


aging of the cicatrix. As the strength of the 
wound increases, the stimulation for growth of 
the tissues involved in the repair will be found 
to decrease. However, repeated injury to a heal- 
ing wound will prolong the effect of the stim- 
ulation for growth. The manner in which this 
is brought about is not known. 

Tissue cultures of fibroblastic tissue show 
that growth will advance just so far and then 
come to a halt. It is not cicatrization, or circu- 
latory ischemia, which stops it because the 
growing cells at the periphery are bathed in 
fresh media and could keep right on growing, 
if so inclined. Obviously, it is not the influence 
of a completed regeneration of an epithelial 
coverage. Epithelial cells do not take part in the 
tissue culture experiments, and, furthermore, 
we know that the healing of concciiled wounds 
behaves the same way with the skin remaining 
intact. It is fortunate that tissue growth does 
slow down as healing advances and that it can 
stop itself at the right time. 

If cultures of fibroblastic tissues are fed until 
the masses stop growing, and if incisions are 
made in these masses, growth will start again. 
Products from the injured cells stimulate the 
regeneration, and this can be repeated on the 
same tissue culture. The effect becomes less 
each time, however, and will not go on in- 
definitely. 

A related effect can be observed in clinical 
wounds. A granulating wound which is too 
large for spontaneous regeneration of epithelium 
may he dressed and carefully tended until 
growth seems to stop. The placement of pieces 
of skin graft in the wound will be found to 
stimulate the marginal epithelium to grow 
again, so that it will have joined the marginal 
grafts before the grafts themselves have started 
to send out new epithelium. In this instance, 
the stimulation must come from the cut epi- 
thelium applied as grafts. 

The stimulating effects of trauma on scar tis- 
sue can readily be observed in many postopera- 
tive incisions. Patients leaving the hospital 
during the second week following their opera- 
tions will be free of skin sutures and will show 
smooth, soft, hair-line approximations of their 
skin incisions. When observed over the suc- 
ceeding months, many of the incisions will 
become hard, raised, deep red in color and will 
stretch from % to % inch in diameter. These 
axe hyperplastic scars. They will recede in due 
tiine unless the patients are \thid formers^' 
(Fig. 5). This type of hyperplastic scar is com- 


5 *> 


Physiology of Wound Healing 


29 


B 



A C 


Figure 4. The power of scar contractures. A, Extensive areas of granulation tissue following severe burns. 
Epitlielization was assisted by grafts. B, Hyperextension contracture of the wrist. C, Flexion contracture of 
the neck causing eversion of the lower lip. 



A B 

Figure 5, The stimulation for tissue growth created by an injury becomes abnormal in some patients. 
Keloid has formed in the margin of a burn which was partially covered with skin grafts. B, Keloid formation 
donor sites for skin grafts, 


30 


Chapter 2. Physiology of Wound Healing 



Figure 6. Cicatrix on a leg showing its suscepti- 
bility to injury and infection. A chronic ulcer has 
appeared in the dense nonpigment-hearing scar. 

monly found in areas where the skin closure is 
under tension resulting from loss of skin; 
stretching from muscular activity; increased 
tension from heavy fat deposits; and stretching 
of the abdominal wall from intestinal disten- 
tion, ascites, tumor or pregnancy. However, 
such wounds are sufficiently strong to resist 
total disruption. Prolonged splinting will pre- 
vent the overgrowth of scar, but any excess 
maintained for a long period of time will stretch 
the matured scar into an ugly mark. Excessive 
scar tissue is very susceptible to trauma, and 
small hemorrhages or chronic ulcerations fre- 
quently occur beneath, or in the epithelium 
covering, the scar tissue (Fig. 6). 

Thus far, it has been necessary to assume that 
epithelization of the wound had gone on to 
completion. It must he remembered, however, 
that granulation tissue, starting to mature at 
the periphery of the wound, can reach an ad- 
vanced state of cicatricial formation without 
epithelial coverage. Epithelial growth is of 
prime interest since the functions of intact skin 
are so important. It is protective as a covering 
of the body surface, resisting bacterial invasion, 
regulating temperature, and preventing loss of 
blood and lymph. It permits muscular contrac- 


tion and expansion, rcniaiiis soft and siipp 
yet seldom wears out. It absorbs benehc] 
effects from light but throws down a barri 
of pigment in an effort to pre\'ent ()\'crclose. 1 
counteract drying and reduce reaction, it w 
cover itself with oil. Cutaneous epithelium 
in a constant state of regeneration, the deep 
cells replenishing the suj^pl}' ol new cells 
compensate for the constant shedding of ol( 

After injury, areas of regenerated epitheliin 
will not retain all of these functions. A frt 
graft of skin may carry with it portions of o 
glands, sweat glands and hair follicles, hi 
these elements do not form in the new cpitlv 
lium which grows spontaneously from tb 
margins of the wound or the graft. 

Epithelial growth starts immecliatx'ly aftc 
injury, if it has a place to grow, d'he close! 
approximated wound and the abrasion will pei 
mit prompt growth. The jagged wound wit! 
frayed edges of dcvitali'/cd skin cannot grov 
epithelium until the dead tissue is remo\x'cl. / 
wound with sharp edges and no approximatioi 
will not grow epithelium until the clot besid< 
it is organized into granulation tissue. Epithe 
lium will not grow across Fibrin unless there ii 
active circulation immediately beneath it. Epi 
thelium does not grow readily downward intc 
a hole, or upward over a hill which is at right 
angles to its surface. It grows slowly in large 
wounds and often will stop growing before tlie 
contraction of the scar is complete, thus leaving 
most of the wound uncovered. When granula- 
tion tissue is just right for epithelial growth, the 
rate of coverage is most rapid. 

The corium of normal skin is derived from 
the mesoderm while the epidermis comes from 
ectoderm. The sweat glands, oil glands and 
hairs are ectodermal in origin. The real focus 
of skin regeneration is from stratum germinati- 
vum of the epidermis. In working with split 
thickness grafts of skin, one finds little trouble 
in getting any thickness of graft to grow, pro- 
vided the cut surface does not extend deep to 
the papillae to include a layer of adipose tissue. 
Free adipose tissue transplants poorly, and 
when left attached to the undersurface of a 
skin graft, jeopardizes ‘'take'’ of the graft. 
Grafts taken deeply into the corium will retain 
good pigment and a sufficient amount of elastic 
fibers to impart good cosmetic and functional 
properties to the graft. The preservation of a 
portion of stratum germinativum of the epi- 
dermis is the surest way to obtain epithelial 
regeneration. 


31 


Physiology of Wound Healing 


Ratlier fantastic accounts are given of the 
capacity of the epithelium to re-establish con- 
tinuity in brief periods of time. In these in- 
stances, the wounds are minor, and perfect 
appositions of the parts are required. When 
these conditions are provided, it is sometimes 
ailScult to tell where the injury had occurred 
after a period of twenty-four hours. 

Crusting, or the formation of a scab, in small 
wounds is Nature’s way of simplifying wound 
care and wound healing. The drying of the 
wound's seepage creates a tough, elastic film 
over the unhealed surface. This film sticks to 
the dry superficial cells of the epidermis so 
that the epidermis is securely held in place. 
Additional bacteria rarely get through; and if 
those beneath do not cause a serious infection, 
the crust will stay on until epithelization is 
complete and strong. To many surgeons, crust- 
ing is regarded as something used by Nature 
for the healing of nonsurgical wounds. This 
is an error, because in some degree it is found 
to cover the skin edges of sutured wounds, even 
those most carefully approximated. It makes 
possible the early removal of sutures in wounds 
of cosmetic importance so that scars are not 
produced by the sutures themselves. The sub- 
stitution of some variety of cutaneous adhesive’ 
dressing will protect the wound from damage 
by violence. 

To a lesser degree, scab formation occurs 
at the periphery of the larger open wounds 
beneath which the growth of epithelium may 
be studied. Tongues or sheets of cells, coming 
from the stratum germinativum of the epi- 
dermis, make their w^ay by enzymatic action 
through the fibrin under the crust. If mechani- 
cal effort is made to remove the crust which 
is adherent to the epithelium in the early days 
of healing, some of the fresh epithelium may 
come away with the crust. Spontaneous sep- 
aration of the crust will occur in about two 
weeks. 

It is important to have a clear understanding 
of these principles so that one does not hinder 
the regeneration of skin by vigorous attempts 
to cleanse wounds. The use of lubricated dress- 
ings on open wounds has come about as a 
means of protecting the delicate strands of epi- 
thelium beneath the peripheral crusts. Any 
other dressing which would adhere to the 
crusts cannot be removed without pulling away 
many of them with their epithelial elements. 
Dressings designed to be left in place for many 
days have not been wholly satisfactory because 


of the retention of the irritating drainage from 
the granulating wounds. Although crusts never 
really dry under lubricated dressings, they do 
stay gummy and remain in place. 

Pigmented cells will migrate into new epi- 
thelium if the area is not wide. The size has 
not been established because there are many 
variables which affect the migration. In dark- 
skinned people, all depths of the epidermis are 
pigmented, but the deepest cells are the most 
heavily pigmented. It is interesting to watch 
pigmentation develop in the larger, spontane- 
ously healed burns of the Negro. The deep 
second degree burns which have regenerated 
spontaneously show a pigmented honeycomb 
effect. The comb itself is black and represents 
the deep valleys between the papillae filled 
with stratum germinativum which survived the 
burn. The part of the comb intended for 
honey is red. It represents the epidermis burned 
through into the corium at the apices of the 
papillae with recent regeneration of epithelium 
and no pigment. In due time, the pigmentation 
becomes confluent. If the burn should go a 
millimeter or two deeper, the pattern is re- 
versed. The red epithelium takes the honey- 
comb design while the pigmentation becomes 
spotted. This represents the deepest aspects of 
the papillae toward the subcutis side with 
preservation of the merest fragment of stratum 
germinativum. Such a wound may also become 
pigmented ultimately throughout. 

Following the epithelization of granulating 
wounds, papillae formation is very poor. Glands 
and hair follicles do not form, and elastic fibers 
appear very slowly, if at all. Even then, it may 
be months or years before they are present in 
the more favorable locations at the periphery 
of the wound. 

Sensation will return to skin grafts, and to 
spontaneously epithelized wounds, if the per- 
ipheral nerves are intact and if the granulation 
tissue is not so thick as to be impervious to the 
growth of nerve fibers. The degree of sensation 
may he expected to improve up to one or two 
years after injury. 

With the exception of the cellular elements 
which are carried in the hlood, the bulk of 
the work in the basic processes of wound heal- 
ing which go on in all types and sizes of 
wounds is done by the fibroblasts, endothelial 
and epithelial cells. This holds equally well 
fox injuries to special tissues. 

Because of the multitude of variations which 
may arise as a result of the wound's location,, 



Chapter 2 . Physiology of Wound Healing 



Figure 7. First intention Kealing. The thin line on 
the neck represents the healed incision through which 
a radical neck dissection was done, 

size, shape, duration, causative agent, and 
treatment, some method for sorting and grad- 
ing wounds in relation to the character of their 
healing is of practical value. A classification 
is helpful in the study, evaluation and teach- 
ing of wound management. Galen, in the sec- 
ond century A-d., is given credit for devising 
the terms of primary and secondary healing; 
and as the terms continue to be in everyday 
use, it is necessary to sort out certain features 
of wound healing and group them according 
to their applicability to these terms. 

PRIMARY HEALING 

This type of healing is nearly always de- 
scribed as wound healing at its best. It is heal- 
ing by first intention (Fig. 7). Itis the healing 
of a closed, or concealed, wound without the 
complication of infection, or the secondary 
opening of the wound for the release of blood, 
lymph, seruni' body secretion or excretion, or 
foreign body^It will include the ideal wounds 
as well as those which show e dem a, discolora- 
tion, or hax^^ from excess Iblood, as some 
granulation tissue forms in the majority of 
closed wounds. It is wrong to set up a classi- 
fication which would preclude this fact. Ac- 
ceptance of the thought that the majority of 
the wounds which heal per pximam do so 
through the formation of granulation tissue 
places no restriction on the effort to approach 
the ideal of wound healing and gives a cate- 
gory for the wounds not belonging in the 
class of open wounds. 

In srnne classical examples, scarcely any cel- 


lular reaction is described in response to the 
injury which was made so smoothly that prac- 
tically no cells were destroyed. The wound 
is aseptic; the parts are approximated accu- 
rately f’ hemostasis is so perfect that no ’'fluid 
forms ^yyi thin or leaks from the wound; and 
scar tissue is minimal or absent alter healing. 

A description like this nearly removes ]iri- 
mary healing from the realm of surgery and 
places it out of reach of practicabilit}a 1 lealing 
is a reaction, and without any reaction, heal- 
ing would not occur. To eliminate all hyper- 
emia about a wound is an impossibility. The 
reaction from a pin scratch, or from the injec- 
tion of a local anesthetic, may last lor days. 
The mere preparation of skin with its shaving 
and scrubbing can reduce it to a state of 
'weeping’' with plasma before the incision is 
made. Every primary dressing that is changed 
is stained with wet or dried fluid from the 
wound. No incision can be made through the 
skin without leaving some scar. Surgical tech- 
nique cannot be expected to outdo Nature. The 
ideal wound has to be coddled just as long 
as any standard wound, to insure healing with- 
out complication. 

The reaction is more quantitative than qual- 
itative throughout the steps of repair in primary 
healing. When the tissues are in accurate appo- 
sition and when surgery has clFcctcd most of 
the desirable requirements for good healing in 
a closed wound, there will be a minimal reac- 
tion and less work for the tissues to do. One 
cannot speed the healing, but one can control 
the factors which are capable of delaying it, 

SECONDARY HEALING 

It is probable that the idea for giving this 
type of healing the title of healing hy second 
intention came from the recQgnitiQ,i).,j£, second 
auempts at healing by , wounds . starting,, 
welL of 

suppuradon. We still regard the healing of 
such wounds as secondary (Fig. 1), Generally, 
our minds carry us to the more spectacular 
examples found in the larger, open wounds 
created by surgery, disease, or accident which 
were not closed. Open wounds which heal 
without becoming acutely infected do so by 
secondary intention. They cannot heal by first 
intention, unless the surgical attention given 
them at the time of the injury provided for 
them a skin coverage hy flap graft, or free 
skin graft. In this case, the wounds would 
no longer be ^'open” and would then qualify 



33 


Third Intention Healing 


for primary healing, if the skin coverage were 
to remain intact. The detailed description of 
the organization, aging of granulation tissue, 
and epithelization is ah accurate account for 
the healing of a wound by second intention. 
It is not the quantity of the granulation tissue 
which distinguishes the two, but the absence 
of epithelial coverage that accounts for sec- 
ondary healing. 

THIRD INTENTION HEALING 

An open granjilating _wound, which is 
assisted in its healing by an operat^ proced- 
ure, is changeT'TrohTTeSi^^^ inten- 

tion to healing by thiri intention. Again, the 
implication is that" the" accomplished 

after a third attempt. This is not always the 
case, because often no opportunity was given 
for the wound to heal by first, or second, inten- 
tion. It is a little disturbing to be told that 
a wound, upon which a secondary closure has 
been done, actually heals by third intention. 
If primary and secondary healing include all 
stages of growth of granulation tissue and epi- 
thelial coverage is eventually acquired in both, 
what new and different process in wound heal- 
ing takes place in third intention healing? 

Third intention healing is a convenient term 
for • surgeons. In the strictest sense, it implies 
the use of a skin graft, or delayed closure, in 
the treatment of a granulating wound which 
is healing satisfactorily by second intention, in 
an effort to obtain earlier healing, less morbid- 
ity, and a more functional and cosmetic result. 

The physiologic process of wound healing is 
subject to great variations. Optimum wound 
healing is the normal rate of wound healing 
under physiologically normal conditions. Num- 
erous experiments, of Howes and others, have 
shown that there is no known substance for 
topical or systemic use, which will accelerate 
the rate of wound healing beyond the normal 
physiologic rate. The variation in wound heal- 
ing is one of retardation or limitation caused 
by a number of factors, both local and systemic. 

LOCAL FACTORS IMPAIRING HEALING 

Medications which 'Teak' wounds may be 
looked upon in the same way that teachers 
*learn'' their pupils. Both assist in the accom- 
plishment of the respective goals, but, just 
as the pupils do their own learning, tissues 
do their own healing. 

Tissues have their own normal rates for 
growth in the process of healing. This rate is 


approached when all of the variables advan- 
tageous to the healing rate are present in a 
normal amount, and when all of the variables 
having the ability to disturb or retard the heal- 
ing processes are controlled or absent. 

Devitalized Tissue and Necrotic Tissue. 
These terms are not to be used interchangeably. 
While each is nonliving tissue, necrotic tissue 
implies greater advancement of tissue degenera- 
tion. 

In a fresh wound of violence, one may find 
detached pieces of fat and muscle which, when 
freed of blood and dirt, can be made to re- 
semble closely the tissues remaining in the 
wound. Structurally, the living and detached 
tissues may be the same except for the property 
of bleeding. However, these detached tissues 
are devitalized, that is, detached from life. If 
returned to the wound, it is unlikely that they 
will survive as grafts. If they fail to live, they 
lose the color and firmness associated with liv- 
ing tissue. Individually, the cells break down 
and, as a group, the tissues soften, fall apart 
and liquefy. The process is one of necrosis and 
the tissues are necrotic. 

The removal of devitalized tissues in fresh 
wounds, by various techniques of debridement, 
has become an accepted measure in their opera- 
tive care. It is customary, in some hospitals, to 
regard the surgical treatment of a fresh wound 
as a 'Hebridement,” regardless of the fact that 
tissue may not have been removed during the 
operation. 

When devitalized tissues of significant quan- 
ity are allowed to remain in wounds, they 
proceed to become necrotic. The number of 
enzymes, the leukocytic response, the capillary 
permeability, the fluid loss, and the absorption 
of toxins from the wound are increased. 

Dead, or devitalized, tissues are locally irri- 
tant, serve as an excellent pablum for the 
growth of bacteria, and divert energies of liv- 
ing cells from the problem of repair to the 
problem of elimination of foreign materials. 
Foreign body reaction occurring about foreign 
bodies, or dead tissue, may delay wound heal- 
ing and foster infection. 

Locally, the swelling, redness and tenderness 
will exceed expectations. Open wounds will 
have profuse drainage and the material will 
be of exudative nature. Both fibrosis and epi- 
thelization are delayed. Not until the necrotic 
tissue is expelled or removed by the mechani- 
cal means of excision or dressings, will the 
drainage subside and healing progress. 



34 


Chapter 2. Physiology of Wound Mealing 


It is, therefore^ important that devitalized 
or necrotic tissues resulting from injury should 
be removed by surgical dissection before active 
bacterial growth and infection have developed. 
It is also important that the surgical treatment 
does not result in any unnecessary trauma to 
the tissues during or after the operation. 

Infection. Infection is the greatest enemy 
of wound healing. The development of any 
infection, particularly in large wounds, almost 
certainly increases the period of morbidity 
after operation since it produces furAer de- 
struction of tissue and suppresses the process 
lieilmg. TissiiercteSroyed by' infection are 
usually replaced by scar tissue, which may 
affect function as well as cosmetic appearance. 

The surfaces of the human skin and mucous 
membranes, normally, are contaminated with 
bacteria. The mircoorganisms lie in pits, 
creases, glands, and hair follicles beyond the 
reach of surface washing. When the bodys 
surface is penetrated by trauma, bacteria cross 
the cutaneous protective barrier and penetrate 
the physiologic interior. They may also be 
carried into a wound by the object producing 
the trauma, or by foreign bodies. 

Experience has shown that bacteria may be 
present in a wound without producing the 
slightest clinical evidence of infection and that 
certain factors influence their growth and de- 
velopment. Healthy tissues have a remarkable 
capacity to kill bacteria, or withstand their 
effects, while unhealthy, irritated, or devital- 
ized tissues have limited or little power of 
resistance to their action. Dead tissue in a 
wound invites and supports the growth of 
virulent organisms, as well as nonvirulent or 
saprophytic ones. Therefore, it is extremely 
important to remove any potential pablum for 
bacteria and to prevent the development of 
a similar breeding ground during the post- 
operative state. 

On the other hand, the apposition of live 
tissue to live tissue after the thorough removal 
of all foreign, dead, or dying tissue promotes 
healing even in the face of some contamination. 
The physical condition of the patient is an 
important predisposing factor to infection. De- 
hydration, shock, malnutrition, exhaustion, un- 
controlled diabetes and anemia may lower his 
resistance sufficiently to permit bacterial in- 
vasion. 

Just as the fibroblasts, angioblasts and neu- 
trophils have enzymes to help them to make 
their way ffito fibrin, bacteria have toxins* and 


enzymes to take them through the tissue bar- 
riers within the wounds. The powers of ma- 
terials liberated by injured cells are slight, 
when compared with the potencies of those 
produced by bacteria. It is little wonder that 
the surgeons prefer to look upon “inflamma- 
tion" as the handiwork of bacteria and exclude 
the reactions of uncomplicated repair. 

The staphylococcus produces a coagulasc 
which clots small vessels and favors sjircad 
by septic emboli and hastens local gangrene. 
Some staphylococci and streptococci produce 
hemolysins which break up red blood cor- 
puscles to stain the tissues, produce a brownish 
discoloration to the drainage, and contribute 
to the development of anemia in severe infec- 
tions. 

The streptococcus may also produce a fibrino- 
lysin which makes it difficult for the tissues 
to wall off a streptococcal infection, since 
granulation tissue is required for this purpose, 
and the growth of granulation tissue is de- 
pendent upon the deposition of fibrin. This 
enzyme is known as streptokinase and is com- 
mercially available for therapeutic use against 
heavy deposits of fibrin. 

Streptodornase is another enzyme complex 
produced by streptococci. Its action is on, the 
constituents of nuclei and cytoplasm of cells, 
particularly leukocytes found in pus. Some of 
the enzymes in the dornase factor are believed 
to be hyaluronidase, ribonuclease, dcsoxyribo- 
nuclease, nucleotidases and nucleosidases. 

Most organisms produce proteinases which 
assist in the general breakdown of proteins. 
Special ones, such as collagenase, permit them 
to penetrate fascial barriers. The human bite 
infections are famous for this and much of 
the credit goes to the Bacteroides melanlnogenv 
cus and the anapobic streptococcus. The for- 
mer produces a black pigment, and contributes 
to the putrid smell of lung abscesses, dirty 
mouths, appendiceal abscesses, and infections 
of the human bite. Its enzymes readily dis- 
solve^ fascia, ligaments and tendon sheaths 
to cripple permanently its victims. 

Clostridial organisms may work singly, or 
in combination. Some produce strong protein- 
ases, others saccharolytic enzymes which fer- 
ment muscle sugar into gas and acid. It is 
believed that hyaluronidase acts as a spreading 
factor and assists in the dissemination of their 
toxins. Other bacteria also produce hyaluroni- 
dase presumably for the same purpose. The 
proteinases of some Clostridia are very potent. 



35 


Local Factors Impairing Healing 


The proteinase and collagenase of CL hhto- 
lyticum are capable of completely liquefying 
the muscles and fascia of the extremity of an 
animal or a man. 

Some bacteria, such as the staphylococci, 
streptococci and clostridia, can produce necro- 
tizing enzymes capable of producing necrosis 
of tissue by direct contact. In addition, spon- 
taneous bleeding from infected granulation tis- 
sue has been associated with the products 
of growth of certain bacteria. In active infec- 
tions, combinations or all of these enzymes may 
assist the microorganisms in their penetration 
and destruction of the tissues. Edema secon- 
dary to infection may interfere with circulation 
and foster necrosis, as in gas gangrene. 

In brief, toxins produced by bacteria may 
account for hyperemia, increased capillary 
permeability, edema, spontaneous bleeding, 
clotting, clot and tissue liquefaction, and frag- 
mentation and death of tissue cells. Moreover, 
combinations of bacterial toxins possess a 
synergistic effect. Enzymes liberated from dead 
and dying cells in combination with bacterial 
enzymes may further tissue reaction. 

Foreign Bodies. A mass which is not 
normal for the tissues in which it is found is 
a foreign body. In the broad sense, it is not 
entirely true that a foreign body is something 
introduced from the outside. Tissues can pro- 
duce their own foreign bodies such as urinary 
calculi, salivary calculi, gallstones, calcium 
deposits in areas of old injury, or uric acid 
crystals of gout. 

Foreign bodies produced by the tissues may 
be liquid. Following injuries to glandular tis- 
sues, their secretions or excretions escape from 
normal channels and become foreign for the 
surrounding structures. Examples of this in- 
clude the distention with saliva of a closed 
wound of the cheek which had caused dam- 
age to the parotid gland, free bile in the ab- 
dominal cavity from a ruptured bile duct or a 
lacerated liver, leakage of pancreatic juice fol- 
lowing injury to this gland, extravasation of 
urine following trauma to the urinary tract, 
and leakage of gastric or intestinal secretions 
into the abdominal cavity after perforation of 
a hollow viscus. 

Abnormal accumulations of blood and lymph 
in tissues may be classed as foreign bodies. 
Flematomas and fluid accumulations of serum 
and lymph in large closed wounds are inert 
materials, abnormal for the tissues, and they 
are treated by the host as foreign bodies. A 


mass of tissue which dies, and is allowed to 
remain in place, also falls into the category 
of a foreign body. 

Obviously, the reactions will present great 
variations. To acquire good clinical judgment 
about the management of foreign bodies, one 
should analyze their attributes in relation to 
tissue responses. Most of the reactions to for- 
eign bodies can be traced to the physical 
and chemical natures of the bodies themselves, 
the state of health of the tissues about them, 
and the presence of bacteria. 

A continuous search is being conducted for 
metals which are strong, light, noncorrosive, 
malleable and nonirritating. The ones which 
come closest to the ideal are used as foreign 
bodies intentionally placed in certain wounds 
to serve a useful purpose. When the reaction 
is minimal, the tissues tolerate them and encase 
them in scar tissue. 

Many metals not considered desirable for 
use in surgery are tolerated by tissues which 
surround them with scar, but a delayed injury 
from their presence may be suffered. Lead 
bullets may slowly decompose to produce lead 
poisoning. Iron may corrode. A fragment 
lodged in an eyeball may cloud the tissues with 
pigment and cause blindness. Sharp objects, 
such as needles, may travel through the tissues 
from the effects of pressure endured during 
exercise, and introduce complication by their 
penetrations. Large and irregular objects rest- 
ing against pressure areas may produce erosion. 

Other physical attributes affect tissue toler- 
ance. Porous materials are tolerated less well 
than the solid and impervious ones. This is 
especially true when bacteria are growing in 
the wound. A monofilament suture will do 
better than one made with twisted or braided 
fibers. The fewer foreign bodies left in the 
wound and the smaller their sizes, the better 
will be the tissue tolerance. 

Foreign bodies may be the primary irritants 
because of their chemical natures. Strong acids 
and alkalis may effect their own burns, and 
many salts are locally or systemically poisonous. 
Insoluble foreign bodies such as glass, gravel 
and carbon particles can be looked upon as 
inert substances. If not contaminated with 
bacteria, they may remain in the tissues with 
little or no reaction if not removed by operation. 

Organic materials such as grass, straw, cloth- 
ing and wood are not tolerated. The usual bac- 
terial contaminations will cause recurrent 
inflammations until they are removed. 



36 Chapter 2. Physiology of Wound Healing 


Sutures are also examples of foreign bodies. 
Catgut sutures are so chemically constituted 
that human tissues may act upon them and 
destroy them. Nonabsorbable sutures must be 
inert and nonirritative to tissues. 

Homologous skin will grow, but soon appar- 
ently produces antibodies in the host which 
will destroy the grafts about the third week. 
Homologous grafts of fascia, cartilage and 
blood vessels are tolerated much better than 
are grafts of skin elements. The tissues do 
not live, but their forms are preserved for 
structures of fixation by the host’s cells, pro- 
vided the grafts are not complicated by in- 
fection. 

When a foreign body lies in badly damaged 
tissues, its chances of retention within the 
wound are greatly reduced. Since the trauma- 
tized tissue enveloping it is also a foreign body 
which will undergo some degeneration, little 
opportunity is given the living cells to envelope 
and accept it. Liquefaction with drainage may 
dislodge it, or cause it to be an additional 
source of irritation. Great care must be ob- 
served in surgery so that tissues are not 
unduly traumatized when one expects to leave 
foreign bodies within the wound. 

One of the greatest problems of foreign bod- 
ies comes with their relationship to infection. 
Being inert and occupying space, they keep liv- 
ing tissues apart. The larger and more numer- 
ous they are, the greater is their contribution 
to complications in healing. If they are of the 
absorbable kind, the very act of absorption 
creates edema and free fluid which favor bac- 
terial growth. If they are porous, bacteria will 
remain alive within the foreign bodies and 
survive the effects of antibodies and antibac- 
terial drugs, which may give temporary control 
to the reaction in the living tissues. At a sub- 
sequent date, the infection may start again. 
When a reaction about a foreign body is going 
on, drainage from a wound will be copious, and 
complete healing will not be accomplished 
until the foreign material is removed. Tissues 
which formerly seemed to grasp the material 
very securely will be found to soften and with- 
draw from it. Again, the only remedy is re- 
moval. 

It is an accepted fact that foreign bodies 
left in tissues predispose to infection of the 
area at any time. A patient who has carried 
for years a foreign body of one kind or another 
and has had no difficulty from it, may develop 
aii acute reaction and an abscess about the 


object. Sometimes, these arc traced to secondary 
trauma without additional external contamina- 
tion. At other times, the source of the infection 
is unknown, and it is assumed that the organ- 
isms are distributed by the blood to an area 
of lowered resistance. 

Local Blood Supply. To interfere with 
the local blood supply of a wound, even in a 
healthy individual, is like limiting the raw 
materials to a good industry. Production will 
drop off. The process of granulation tissue 
formation and wound healing is impossible 
without an adec]uate blood supply. 

The blood supply may be interfered with 
locally by the injury itself, laceration of re- 
gional vessels such as the popliteal artery, or 
pressure of old or new scar tissue. Swelling 
from contusion, congestion, infection, or tox- 
ins from bites of poisonous animals serve to 
cut down the local supply of blood. VVluUcver 
the cause, impairment of wound healing oc- 
curs. 

Signs of retardation in healing a{>{)ear. lire 
formation of granulation tissue is retarded, 
and the tissues become pale. If blanching is 
produced by digital pressure, the return of 
circulation is sluggish. The skin is cool and 
wounds are slow to cpithelizc and contract. 
The line of incision shows little hyperemia 
and is easily separated. The open wound shows 
pale, wet, soft granulations which grow slug- 
gishly, or fail to grow at all Purulent exuda- 
tion is minimal, but bacterial growth is likely 
to increase tissue destruction. Skin flaps arc 
readily lost, and grafts may fail to take, or are 
easily dislodged by activity. 

Elective surgery should not be attempted 
on tissues known to have poor blood supply* 
In an emergency, everything possible should 
be done to improve the condition accounting 
for the disorder. 

In the care of wounds of violence involving 
tissues which are otherwise normal, the surgi- 
cal therapeutic effort to remove devitalized tis- 
sues from the margins of these wounds is based 
in part on the appreciation of the contribution 
of a good blood supply toward prompt healing. 
Apposition of tissue with an assured supply of 
blood is most desirable. Flaps with precarious 
blood supply must not be impaired with con- 
stricting bandages and tight or excessive su- 
tures. Excessive scar tissue with deficient cir- 
culation which affects the recovery of a part 
should be excised to a good source of blood 
and the defect corrected by a suitable graft. 



Local Factors Impairing Healing 37 


When ischemia develops in tissues which 
have impairment of sensation, marhed pain 
develops. Whether it is produced by an arterial 
embolus, tight dressing, tight cast, tight sutures 
or a distended wound, the mechanism is simi- 
lar. This can be appreciated through two 
simple experiments. Place a blood pressure cuff 
about the arm and inflate it to a degree well 
above the systolic pressure. Record the time 
and see how long it can be tolerated. Second, 
sit in a chair and obtain the most comfortable 
position possible. Extend the legs on a foot 
stool if you wish, and pick up an interesting 
book. From then on do not change the position. 
When ischemia begins to develop over the 
heels, calves, knees, ischial tuberosities, sacral 
area or over the greater trochanter of the femur 
because of the continued pressure, the pain 
will become disturbing enough to interfere with 
the reading. Record the time, and do not move. 
When it becomes most unbearable, think of 
the infant being given an intravenous injection 
in a leg which is strapped too tightly to a 
splint, or the patient who has a lump in his 
cast, or the bed-ridden creature who cannot 
change his position but is turned every four 
hours by a nurse. What part of four hours can 
you sit without moving? 

Edema and Lymphatic Obstruction. When 
stasis of lymph and venous blood begins to 
pile up in a wound, the efficiency of healing 
begins to wane. When lymph flow is ob- 
structed, edema results. When venous flow is 
obstructed, venous engorgement and edema 
result. Oxygen tension in the tissues is re- 
duced; carbon dioxide builds up; the pH falls; 
tissue edema increases; and more stress is placed 
upon the lymphatic channels. Tissue metabo- 
lism slows and the by-products of metabolism 
begin to accumulate in the tissues to produce 
a sense of fatigue and malaise. 

Lymphatic or venous blockage produces 
swelling which is detrimental to wound heal- 
ing and favors bacterial growth. The drainage 
of open wounds increases. Vesicles may appear 
in the skin which may break down and form 
open wounds. Tissues, boggy from edema, will 
have a restricted blood supply. Capillaries and 
venules which do not become occluded with 
clot will be obstructed by pressure. Fibrosis 
in tissue is enhanced by stasis, but fibrosis is 
not a desirable reaction when it extends beyond 
the healing of the wound itself. Fibrosis in 
tissues about a wound weakens the resistance 


of those tissues to future injury and retards 
the repair of those injuries. 

Excellent examples of the effects of lymphatic 
and venous stasis are found in the lower ex- 
tremity. Injuries in the lower third of the leg 
heal more slowly than in any other part of the 
body. Acute and chronic ulcerations occur fre- 
quently and become complicated by fibrosis 
and cicatrization. While other factors enter 
into the problems of wound healing for the 
lower extremities, stasis of blood and lymph is 
a common denominator of all of them. 

The part played by stasis in delaying the 
healing of wounds is evident when one ob- 
serves an ambulatory patient^s leg ulcer of long 
duration heal rapidly as soon as the patient is 
placed at bed rest with the extremity elevated. 
The improvement which comes with bed rest 
is the result of correcting the stasis accompany- 
ing the upright position. 

Anything that can be done to control or 
eliminate stasis will benefit wound healing. 
Elevation of the part for gravity drainage has 
already been suggested. Compression dressings 
have been in vogue for years, but they are diffi- 
cult to apply, and their pit-falls are many. Dur- 
ing the heat of summer, the heavily padded 
pressure dressings applied to body burns have 
contributed to the retention of heat and the 
production of thermal disasters to some pa- 
tients. Constricting dressings about the thorax 
and abdomen may cause respiratory embarrass- 
ment, and pressure dressings on an extremity 
which do not go all of the way to the end will 
serve to increase the stasis and swelling beyond 
the bandage. 

Hemorrhage. Disregarding the effects on 
the individual of having a continued loss of | 
blood to deplete his blood volume or his cellu- | 
lar and serum protein reserves, bleeding into 
wounds does have adverse influences on their 
healing. Ideally, the coagulum should be just 
enough to stick the parts of the wound together ; 
and to eliminate dead spaces. The effects of 
blood accumulation beyond this amount, result- 
ing from the injury, or inadequate stasis during 
operation, are rather clear since the sides of the 
wound will be forced apart. The resulting 
hematoma will increase the tension on the tis- 
sues to produce pain, ischemia, necrosis, and 
delayed healing. Sutures, subjected to the 
stretching effect of an expanding hematoma, 
may cut through and become loose. 

Bleeding in a closed wound will cause the 



38 Chapter 2. Physiology of Wound Healing 


blood to extravasate along planes of least resist- 
ance. Bleeding from severe fractures of the 
pelvis, for example, can extend in the retroperi- 
toneal tissues to the diaphragm, mediastinum, 
and even to the level of the neck. These areas 
can hold more blood than the patient can afford 
to lose, and death is common following such 
accidents. The presence of blood in these areas 
disturbs the innervations to the gastrointestinal 
tract and favors the onset of ileus. 

Extravasated blood in muscle and fascia 
stiffens the tissues, increases the edema, occludes 
capillary flow, impairs the flow of lymph, and 
lessens local resistance to infection. Function of 
a part may be affected by the pain, swelling, 
stiffness, diminished blood supply, and im- 
paired innervation resulting from marked extra- 
vasations of blood. 

Since extravasated blood cannot return to 
the circulation as whole blood, it usually clots 
and slowly undergoes degeneration and absorp- 
tion, while a part of it is utilized in the growth 
of granulation and scar tissues. This, too, in- 
creases the morbidity for the injury and leaves 
behind an undesirable amount of scar to be 
reckoned with during the convalescence and 
rehabilitation. 

There is no circulation within a hematoma 
until it becomes organized. Until that time, 
bacteria within the hematoma cannot he 
reached by systemic antibacterial drugs. Large 
hematomas which are slow to absorb and which 
have not been aided by therapeutic evacuation 
sometimes end in rigid-wall cavities containing 
encapsulated fluid. 

The effect of blood clots being without circu- 
lation can he observed in work with skin grafts, 
[f a hematoma develops beneath a graft, it will 
bold the skin away from its source of nourish- 
nent and bring about its death. The bleb may 
;hen he opened and the contents evacuated. 
The surrounding area of graft, having re- 
nained viable, may he sufficient to provide 
‘.pithelial growth to cover the defect or addi- 
ional grafting may he necessary if the hema- 
oma was large. 

General Factors Influencing Wound Heal- 

ng. Blood Supply. Since living cells con- 
cibuting to the process of healing must receive 
heir energy and materials necessary for growth 
com the circulating blood, any systemic disease 
/hich diminishes the blood supply may impair 
round healing. Diseases producing anemia, 
ardiac decompensation, obliterative arterial dis- 
ase, decreased blood volume, and edema may, 


therefore, have marked effects on the process of 
healing, lire surgeon must, therefore, observe 
carefully the efficiency of the genera) circula- 
tion in order to determine whether or not heal- 
ing is possible, or if it can be inrpro\’ed by 
treatment which renders the circulation more 
efficient. Careful attention should he paid to 
the status of the cardiac function since digital- 
ization may be required to ov'crcome dependent 
edema in patients with cardiac decompensation. 
If the arterial supply to the part is greatly di- 
minished by arteriosclerosis, it may be wise to 
place the injured leg in a slightly dependent 
position to augment the local blood supidy. The 
presence of anemia and decreased blood vol- 
umes should be determined and corrected. 
There is suggestive evidence that the poor 
wound healing observed in severely anemic pa- 
tients is probably secondary to protein and 
vitamin deficiencies more than to the anemic 
state itself. 

Nutrition. A normal physiologic status is 
essential for a normal and most rapid rate of 
wound healing. Alterations in the physiologic 
state may have deleterious effects on tlic heal- 
ing process and must, therefore, be corrected. 
Malnutrition, or diet deficiency, may be the 
cause of lowered resistance in patients. Diffi- 
culty in maintaining cellular nutrition may re- 
sult in failure of the body to mobilize the 
defense mechanism and may even cause local 
conditions favoring the growth of invading 
bacteria. 

In some patients with infections, it has been 
found that there is a complement clcHdcncy in 
the blood. This is a nonspecific element in the 
Hood necessary for defense against invading 
bacteria. 

A deficiency in protein, known as hypopro- 
teinemia, inhibits fibroplasia within the granu- 
lation tissue. Hypoproteinemia may be caused 
by prolonged protein starvation, or by loss of 
protein following severe or repeated hemor- 
rhage, prolonged sepsis, continued inflamma- 
tory exudate, drainage from fistulae, cirrhosis 
of the liver, or ascites. It is frequently asso- 
ciated with tissue edema produced by a loss 
of fluid from the capillary bed into the inter- 
cellular spaces. In the presence of protein de- 
ficiency, the edges of a wound ap}}ear soggy 
with edema, and they may give no evidence of 
fibroplasia as late as the eighth to fourteenth 
day after injury. This may result in disruption 
of abdominal wounds. It is essential to deter- 
mine the presence of hypoproteinemia by meas- 



39 


Local Factors Impairing Healing 


uring the values for serum protein and to 
combat any hypoproteinemia by transfusions 
of plasma or blood and a diet rich in protein 
before and after operation. 

During the period immediately after injury 
or operation, a state of negative protein balance 
is common. An increased protein intake may 
restore a positive balance and provide more 
adequate nutrition. 

Lyons has emphasized that delayed wound 
healing may be observed in patients with a re- 
duced total serum protein volume and a reduc- 
tion in blood volume associated with severe 
wounds or protracted illnesses. Such patients 
are also in negative protein balance. The ob- 
served serum protein and hemoglobin levels 
may be normal in patients with decreased cir- 
culating blood volume. U nder such conditions, 
the administration of liberal amounts of blood 
to patients who have lost 10 to 20 per cent of 
their body weight usually is followed by im- 
proved wound healing. 

Agawi'inaglohinemia is a state of deficiency 
of a special protein, gamma glohin, in the blood 
which decreases the patients resistance and 
favors the development of infections resistant 
to treatment 

Vitamins. It is well recognized that surgical 
procedures and injuries diminish hepatic func- 
tion and that the liver is concerned with the 
metabolism and storage of most of the vitamins. 
Replacement therapy is generally considered 
helpful in maintaining the body at optimum 
efficiency since some of the vitamins play an 
important role in the healing of wounds. 

Several of the vitamins have been shown to 
have special significance in the relation to heal- 
ing of the wounds and infections. Vitamin C 
is required for the production and maintenance 
of the intercellular cement, especially in the 
capillary bed and in the collagenous tissues. 
Lack of, or deficiency of, intercellular substance 
in the granulation tissues and capillary bed re- 
sults in hemorrhage into the wound space and 
into the bordering tissues, prolongs the lag 
period, retards fibroplasia, and delays the devel- 
opment of adequate tensile strength in the 
wound. Vitamin C is also involved in protein 
metabolism through its effect on tyrosine and 
phenylalanine metabolism. Experimental stud- 
ies of Lind and Crandon indicate that minor 
degrees of vitamin C deficiency are not very 
important from the standpoint of wound heal- 
ing. However, prolonged deficiency is associated 
with marked interference with the healing 


process. Like hypoproteinemia, vitamin C de- 
ficiency may be a causative factor of wound 
disruption or dehiscence. 

Some of the components of vitamin B com- 
plex should be added to large doses of vitamin 
C and given to patients after injury or opera- 
tion. It is suggested that during a period of 
acute stress after injury and for two or three 
days afterwards, the patient should receive 1 
gm. of vitamin C, 50 mg. of nicotinic ribo- 
flavin, and 500 mg. of nicotinic acid daily. 
Thereafter, smaller doses of the vitamins are 
recommended until recovery is complete. 

One of the fundamental roles of vitamin A 
in the body is concerned with maintenance of 
the integrity of epithelial tissue. Lack of vita- 
min A may lower local resistance to infection. 
Since this vitamin unites wdth proteins to be- 
come an essential constituent of all specialized 
epithelial tissues, adequate stores are essential 
for epithelization following operations or in- 
juries. In indolent ulcerations, in which the 
infection has been completely controlled, inhi- 
bition of wound healing may persist until large 
doses of vitamin A are given systemically. On 
the other hand, the contention that topical ap- 
plications of vitamins A and D in the form of 
cod liver oil stimulate wound healing has not 
been proved. 

Vitamin K has an essential role in the con- 
trol of hemorrhage in relation to a deficiency in 
prothrombin known as hypopvthrombinemia. 

It is of great importance in patients who are 
jaundiced or who have marked hepatic insuf- 
ficiency. Continued bleeding in wounds of such 
patients wdll result in improper or delayed 
healing. Under such circumstances, the admin- 
istration of vitamin K is of great help in pro- 
ducing effective clotting of blood and in 
preventing continuous oozing into the wounds. 

Adequate intake of vitamin D is required for 
the proper absorption of calcium and its deposi- 
tion in hones. At times it is desirable to pa^ 
special attention to the intake of vitamin D in | 
connection with the healing of wounds or in-l 
fections involving bones. Liver impairment fol-’ 
lowing surgical procedures may interfere with 
the absorption and utilization of vitamin D. 
The need fox supplementation which exists 
following ordinary operations becomes greater 
when bones are involved in the lesion. 

Temperature. Temperature has an effeci 
on the growth of cells and, therefore, on wounc 
healing. In tissue cultures, this effect is wel 
known. It is probable that the ideal tempera-f 



40 


Chapter 2. Physiology of Wound Healing 


ture for the ‘healing of a wound is the normal 
body temperature and that every effort should 
be made to approximate it with regard to dress- 
ings and atmospheric conditions for a wound. 
Patients subjected to refrigeration anesthesia or 
refrigeration treatment for prolonged periods 
may show a marked tendency toward non- 
healing. 

Rest. Rest of the part is of considerable im- 
portance, particularly in relation to wounds of 
the extremities in the region of joints. Motion 
of the area by joint or muscular activity dis- 
turbs the medium in which the cells are grow- 
ing and invites extravasation of blood and fluid. 
However, in abdominal wounds the experience 
of the past fifteen years has amply demon- 
strated that the healing of properly sutured 
wounds is not retarded significantly by early 
ambulation. 

Metabolic Diseases. Metabolic diseases 
such as diabetes and portal cirrhosis may be fac- 
tors which inhibit wound healing. In the case 
of uncontrolled diabetes, a decreased resistance 
to bacterial infection may increase bacterial 
destruction of tissues in wounds and cause pro- 
tracted delays in wound healing. In addition, 
obliterative peripheral arterial disease associated 
with diabetes may affect the local blood supply 
and the process of healing. In portal cirrhosis, 
hypoproteinemia, hypoprothrombinemia and 
vitamin deficiency states may influence the rate 
of healing of wounds. 

Uremia. The experience of the Research 
Team of the U. S. Army in Korea during the 
Korean War showed that wound healing was 
significantly retarded in uremic states which 
developed in some battle casualties as the result 
of massive tissue necrosis or infection, VVound 
healing in civilian patients with uremia like- 
wise appears to be retarded. The reasons for 
this are not clear. 

HEALING OF SPECIAL TISSUES 

Epithelium has marked powers of regenera- 
tion, and injuries involving the skin and mucous 
membrane are usually followed by rapid repair 
and more or less complete restoration of the 
typical cellular arrangement produced by re- 
generation. Mucous membranes of the squa- 
mous type behave much the same as skin. 

3 Tendons heal by regeneration through the 
process of granulation. A moderately rapid 
growth of granulation tissue replaces the exu- 
|ate between the sutured ends of tendons, and 
pbroplastic Proliferation occurs within the gran- 


ulation tissue. New collagen tissue is formed 
and produces firm union of the severed ends. 
Studies of Mason have shown that tlie tendon 
ends start to proliferate about the fourth or 
fifth day after suture and to send out bands of 
cells and fibrils into the adjacent tissue. If the 
tendon is injured, or if it is stri{)ped of its blood 
supply, necrosis is likely to occu r and delay the 
process. After the fourth or fifth day, the ten- 
don itself begins to proliferate and to send cells 
into the coagulum. If the gap is not too great, 
it may be bridged by proliferating cells of the 
tendons themselves. 

Muscle does not regenerate, but heals by 
granulation and scar tissue Formation. Prolifera- 
tion of fibrous tissue from the muscle sheath 
and the intermuscular septa form new fibrous 
collagenous tissue which unites the separated 
muscle and restores its function. A minimal 
amount of scar tissue necessary to fill the 
wound defect in the muscle is advantageous, 
since it is apt to produce less interference with 
the function of that muscle. 1 lealing of muscle 
injuries will not progress until all necrotic and 
devitalized muscle is removed. 

Bone heals by regeneration. It has remark- 
able powers of healing after injury. A clot first 
forms between the two ends of fractured bones. 
Thereafter, typical proliferation of granulation 
tissue develops from the endosteum, the peri- 
osteum, and the haversian canals, along with 
the formation of capillary buds. The osteoblasts 
in the periosteum and endostcunr proliferate 
and lay down new osteoid tissue. The clot is 
absorbed and replaced by vascular tissue and 
new osteoid tissue. Calcium salts arc then de- 
posited in the osteoid tissue making it firm and 
known as cdlus. The superfluous, or excessive, 
external callus is largely or completely absorbed 
until the normal contour of the bone is restored. 
Healing occurs more rapidly in long bones than 
in fiat bones. Bones with little or no periosteum 
are apt to heal slowly. Immobilization of frac- 
tured bones is particularly essential for healing. 
The repair of bone at the site of injury or in- 
fection may be so complete that it may be 
impossible to detect after one year. 

Cartilage may or may not heal by regenera- 
tion, depending upon its location. Articular 
cartilage in joints does not regenerate, whereas 
costal cartilages can regenerate provided the 
perichondrium is present and viable. Only the 
latter produces parent cells capable of produc- 
ing adult chondrocytes which reproduce car- 
tilage. 



41 


Healing of Special Tissues 


Composed of mesothelium, serous mem- 
branes^ such as the peritoneum, have great 
powers of regeneration. Denuding of peri- 
toneum from large areas of the wall of the 
abdominal cavity has been shown to be fol- 
lowed by early regeneration of the peritoneal 
surface. 

As soon as the surfaces of the mucous mem- 
brane of the gastrointestinal tract are united by 
suture an exudate forms and seals the union. 
This exudate is invaded by granulation tissue 
from the subserous connective tissue. Healing 
is usually more rapid than in other epithelial 
tissue. The united mucosa which has been in- 
verted into the lumen by the suture undergoes 
more or less necrosis along the suture line. As 
this sloughs off, however, granulation tissue 
forms and is then replaced by new mucous 
membrane which may in every way resemble 
the normal tissue. Thus, healing is by granula- 
tion of the entire wall except the mucous mem- 
brane, where it is by epithelial regeneration. 
Mucous membrane of the gastrointestinal tract 
has exceptional powers of regeneration. 

Components of nervous tissue do not regen- 
erate unless a neurilemma sheath is present. 
Nerve cells which have been destroyed do not 
regenerate. However, the various fibers of the 
cell may regenerate when the cell itself re- 
mains viable. Division of a peripheral nerve 
may be followed by growth of the axon in a 
peripheral direction and function may be re- 
stored. The connective tissue which grows more 
rapidly than the nerve fibers may surround 
them and impede their further growth. 
Wounds of the brain and spinal cord heal by 
the proliferation of the glial-supporting tissue. 

READING REFERENCES 

Altemeier, W. A.: Treatment of Fresh Traumatic 

Wounds. J.A.M.A. 124:405, 1944. 

Arey, L. B.: Wound Healing. Physiol. Rev. 16:327, 

1936. 

Cole, J. W., Shaw, D. T., and Fraser, P.: Cutaneous 


and Serum Inhibition of Hyalurdnidase; Experi- 
mental Study. Surg,, Gynec. & Obst. 90:269, 1950, 

Cole, J. W., and others: Histologic Study on Effect of 
Cortisone (Adrenocortical Preparation) on Healing 
per Primam. Surg., Gynec. & Obst. 93:321, 1951. 

Findley, C. W., Jr., and Howes, E. L. : Effect of Edema 
on Tensile Strength of Incised Wound. Surg., 
Gynec. & Obst. 90:666, 1950. 

Hartzeil, J. B., Winfield, J. M,, and Irvin, J. L.: 
Plasma, Vitamin C and Serum Protein Levels in 
Wound Disruption. J.A.M. A. 116:669, 1941. 

Harvev, S. C.: Healing as Biologic Phenomenon. 
Surgery 25:655, 1949. 

Howes, E. L., and Harvey, S. C.: Tissue Response to 
Catgut Absorption, Silk and Wound Healing. In- 
ternat. J. Med, k Surg. 43:225, 1930. 

Howes, E. L., Plotz, C. M., Blunt, J. W., and Ragan, 
C.: Retardation by Cortisone of Wound Healing. 
Surgery 28:177, 1950. 

Koch, S. L.: Injuries of the Parietes and Extremities. 
Surg., Gynec. & Obst. 76:1, 189, 1943. 

Lanman, T. H., and Ingalls, T. H.: Vitamin C. De- 
ficiency and Wound Healing. Ann. Surg. 105:616, 
1937. 

Mason, M. L., and Shearon, C. G.: The Process of 
Tendon Repair. Arch. Surg. 25:615, 1932. 

Menkin, V.: Mechanism of Leukocytosis with Inflam- 
mation. Arch. Path. 30:363, 1940. 

Moore, F. D., and Ball, M. R.: Metabolic Response to 
Surgery. Springfield, III, Charles C Thomas, Pub- 
lisher, 1952. 

Penney, J. R., and Balfour, B. M.: Effect of Vitamin C 
on Mucopolysaccharide Production in Wound Heal- 
ing. J, Path, k Bact. 61:171, 1949, 

Pohle, E. A., Ritchie, G., and Moir, W. W.: Effect of 
Roentgen Rays : Histologic Changes in Skin Wounds 
in Rats Following Postoperative Inadiation with 
Very Small and Moderate Doses. Radiology 52:707, 
1949. 

Prudden, J. F., Lane, N., and Meyer, K.; Lysozyme 
Content of Granulation Tissue. Proc. Soc. Exper, 
Biol. & Med. 72:38, 1949. 

Sandbloom, P.: Effect of Injury on Wound Healing. 
Ann. Surg. 129:305, 1949. 

Stevenson, J., and Reid, M. R.: Treatment of Trau- 
matic Wounds. Am. J. Surg. 46:442, 1939. 

Ziffren, S. E., and May, S. C.: Effect of Various 
Enzymes (Streptodornase and Streptokinase, Deso- 
xyrihonuclease and Trypsin) on Infected Wounds 
and Necrotic Tissue. S. Forum (1950) pp. 405-410, 
1951. 

Zintel, H. A.: The Healing of Wounds. S. Clin. North 
America 26:1404, 1946. 



3 


Surgical Bacteriology, Chemotherapy 
and Antibiotic Therapy 

By FRANK L. MELENEY, M.D. 

Frank Lamont MeljExNey xwis educated at Dartmouth College and Columbia Uni- 
versity. He taught mathematics and science before entering medical school. lie 
served on the faculty of the Peking Union Medical College, China, under the 
auspices of the Rockefeller Foundation. A large amount of credit for the low incidence 
and morbidity of surgical infections today is due to his organization of a Laboratory 
for Bacteriological Research within the Department of Surgery at Columbia Univer- 
sity and his insistence upon close cooperation between the surgeon and hacteriologlsL 
Bacitracin was developed, tested and clinically proved under his stipends ion. Dr. 
Meleney is Professor Emeritus of Clinical Surgery at Columbia University. 


RELATIONSHIP OF BACTERIOLOGY TO SURGERY 


WHY SHOULD A SURGEON BE INTERESTED 
IN BACTERIOLOGY? 

Coatamination of Operative Wounds. 

Every operative wound made by a surgeon is 
contaminated with bacteria. Before the dawn 
of antiseptic and aseptic surgery the vast ma- 
jority of surgical wounds became infected. This 
effectively limited the scope of operations to 
emergency measures on superficial, easily ap- 
proachable lesions. The inner parts of the body 
were unapproachable, because of the fatal out- 
come of any infection within them. Thanks to 
the great geniuses, Pasteur and Lister, ways 
and means have been found by which we pre- 
vent the occurrence of wound infections. All 
of the thousand and one steps in the sterile 
technique which have been elaborated are di- 
rected toward minimizing the contamination 

Dr. John Lockwood’s contribution on the chemo- 
therapy of surgical infections in the Fifth Edition of 
this Textbook has been revised by Di. Meleney and 
; incorporated into this chapter. The death of Dr. 
iLotkwood, early in life, removed a surgeon from 
I this particular field of research who had been stimu- 

; lated and encouraged hy Dr. Mdeiiey. 


of the operative wound. The surgeon must 
know the sources from which the invading or- 
ganisms come and must develop his sterile 
sense to such a point that he will not be re- 
sponsible for any contaminition which might he 
avoided. 

Surgical Infections. A large part of a sur- 
geon’s practice concerns lesions whicli have 
been contaminated with or infected by bac- 
teria before the patient comes to him. Any one 
who visits a general hospital and makes the 
rounds from bed to bed in any general surgical 
ward will find many of them occupied by the 
victim of an infection which was established 
before he entered the hospital or hy the victim 
of an injury associated with a imtcntially in- 
fected wound. Any one who visits the surgical 
outpatient department finds an even larger 
proportion of infections among the patients 
who are treated there. The surgeon must there- 
fore know how to treat lesions which have 
been produced hy bacteria or which have been 
contaminated hy them. 

Postoperative Infections. Bacteria are fre- 
quently responsible for serious postoperative 



43 


Relationship of Bacteriology to Surgery 


:omplications. As a result of the anesthetic 
di of the operative procedure itself, there are 
certain disturbances of the normal physiology 
of the respiratory, alimentary and urinary 
tracts. At such times bacteria may invade the 
physiologic interior of the body. Furthermore, 
in his efforts to restore the normal physiology, 
the surgeon or his aides may introduce bacteria 
into regions which are normally free from them. 
The surgeon must know how to avoid these 
physiologic disturbances and how to prevent 
the contamination of clean tissues during and 
after operation. 

NECESSITY FOR “STERILE TECHNIQUE” 

Before and After Lister. In this present 
day and age any one who attempts to perform 
surgical operations conforms more or less rig- 
idly to certain rules of procedure known as 
''sterile technique.’' Just so far as these rules 
are followed, infections of operative wounds 
are reduced; just so far as these rules are ig- 
nored, infections of operative wounds are in- 
creased, Only those whose practice extends 
back over sixty years have any conception of 
the state of affairs before the various steps in 
sterile technique were adopted. However, vivid 
word pictures have been left for us to read, and 
frequent reference should be made to them 
"lest we forget” what would surely be the out- 
come if we abandoned the practices which we 
now employ. 

Nowadays a study of wound infections in 
clean cases gives no adequate picture of what 
occurred before 1875, but it reveals the fact 
that there are still sources of wound contamina- 
tion which have not been eradicated. Doors do 
not have to be opened very widely for bacteria 
to enter from a number of different directions, 
and the modern surgeon must be on guard con- 
stantly to keep every means of entrance closed. 

Present-Day Sources of Contamination of 
Clean Wounds. If one were to ask the aver- 
age surgeon how often his clean wounds be- 
come infected, he would probably answer, 
"Very seldom, not once in a hundred times,” or 
"I haven’t had an infection in years.” Unless 
that statement is backed up by actual records, 
the chances are that it would be an under- 
statement of the facts. In most hospitals care- 
ful records of wound healing are not kept. In 
some hospitals, however, such records are kept 
and analyzed at frequent intervals in order to 
keep the staff keenly alert to prevent wound 
contamination and to improve the record of 


wound healing. In one such hospital where 
the question was studied carefully for eighteen 
years, where the records have been scrupu- 
lously kept for every clean case in which an 
operation has been performed and where the 
condition of the wounds at subsequent dress- 
ings has been consistently scrutinized, the fol- 
lowing facts were brought out: 

1. General impressions regarding wound 
infections are not accurate. The actual number 
will vary from 5 to 20 per cent or more 
of all clean cases. Of these, from 1 to 5 per 
cent will be serious, resulting in pain, fever, 
suppuration, weakness of the wound, disrup- 
tion or hernia, prolonged hospitalization and 
occasionally death. The others may be called 
trivial, but they are annoying to the patient 
and usually delay his departure from the hos- 
pital. In the average case of infection the pa- 
tient must remain in the hospital just twice as 
long as the patient in whom infection does not 
occur. 

2. The organisms which have been cultured 
from wound infections in clean cases give a 
clue to their origin. 

Over a period of eight years in the Presbyterian 
Hospital, New York, while there was complete mask- 
ing of the nose and throat of all persons entering the 
operating room, a record was kept of the various organ- 
isms found in the inflammatory exudate of clean wound 
infections. The percentage of incidence of these organ- 
isms is shown in Table 1. It is seen that the staphylo- 
cocci comprised by far the most common group, occur- 
ring in two-thirds of all the infections. The hemolytic 
Micrococcus pyogenes var. aureus (^Staphylococcus au- 
reus') was found in almost one-third of all tbe serious 
infections, and the Micrococcus pyogenes var. alhus 
CStaph, alhus) was the chief offender in the trivial 
infections, being present in almost two-fifths of the 
cases. The hemolytic and nonhemolytic streptococci 
were found in 4 and 5 per cent, respectively. The hemo- 
lytic variety was more serious than the nonhemolytic, 
and both of them were found more often in serious than 
in trivial infections. Escherichia coli and Proteus vul- 
garis were somewhat more likely to produce serious than 
trivial infections, and Pseudomonas aeruginosa ((Bacil- 
lus pyocyaneus), while not occurring so frequently, was 
invariably serious. On the other hand, Bacillus suhtilis 
and the diphtheroid bacilli, which are ordinarily not 
considered pathogenic, occasionally caused trivial infec- 
tions and when found were frequently in pure culture. 
Among the ^^others,’’ the only organism of importance 
was Clostridium perjringens (CL welckii), which oc- 
curred once in an amputation stump and was probably 
present in the gangrenous foot requiring the ampu- 
tation. 

Where did these organisms come from) We know 
that staphylococci are frequently found on the skin 
and probably frequently lodge, live and perhaps grow 
in the sebaceous and the sweat ducts and in the hair 
follicles. They are also commonly found in the air. 



44 Chapter 3. Surgical Bacteriology, Chemotherapy and Antibiotic Therapy 


TABLE 1. INCIDENCE OF THE VARIOUS ORGANISMS FOUND IN CLEAN WOUNf) INFECTIONS 
FOR EIGHT YEARS OF COMPLETE MASKING AT OPERATION 


ORGANISMS 


SERIOUS TRIVIAL TOTAL 

(percent) (percent) (percent) 


Hemolytic streptococcus 

Nonhemolytic streptococcus 

Hemolytic Micrococcus pyogenes var, aureus . . . 
Nonhemolytic Micrococcus pyogenes var. aureus 

Micrococcus pyogenes var. albus 

Escherichia coli 

Proteus vulgaris 

Pseudomonas aeruginosa 

Bacillus suhtilis 

Diphtheroids 

Others 


9 

7 

32 

13 

19 

7 

3 

4 
4 
0 
2 


4 

16 

14 

38 

6 

2 

0 

7 

6 

4 


4 

5 

22 

14 

31 

6 

3 
1 
6 

4 
4 


When blood agar plates have been exposed in an op- 
erating room while an operation was in progress, as 
many as one to two colonies of bacteria per minute of 
exposure have appeared after the plates have been in- 
cubated, This would mean that from 30,000 to 60,000 
bacteria are deposited from the air on the sterile held 
during the average operation. Staphylococci represent 
a large proportion of these organisms. If plates are ex- 
posed in an operating room when no operation is in 
progress and no one enters, the number of colonies is 
reduced to 10 per cent of the above figures. They are 
almost invariably present also in the human nasal pas- 
sages and are discharged during expiration. These or- 
ganisms occasionally also contaminate the operating 
room tables, the pads or the floor when the pus from 
infections caused by them is allowed to escape at the 
time of operation. Likewise, the floor of the operating 
room may be contaminated with staphylococci from 
material which is brought in on street shoes and which 
when dried may he carried about on currents of air. 

Streptococci axe not commonly found on the skin 
but are occasionally found on blood agar plates ex- 
posed to the air. TThe hemolytic variety is frequently 
found in the throat and more rarely in the nose. The 
nonhemolytic streptococci are invariably present in 
the throat and are frequent in the nose. Both staph- 
ylococci and streptococci are often picked up by the 
hands and clothing of doctors and nurses when han- 
dling or dressing patients. Both streptococci and 
staphylococci are easily killed by relatively low de- 
grees of heat and could hardly escape death in the 
autoclave or instrument sterilizer even when too brief 
or inadequate temperatures fail to kill many other 
organisms. For that reason, supplies and instruments 
and catgut may be practically eliminated as possible 
sources of these organisms, unless they have been con- 
taminated from other sources after sterilization. 

B, suhtilis and the diphtheroid bacilli are of little 
importance, although B, suhtilis, which produces a 
resistant spore, is an excellent test organism for the 
adequacy of sterilization. Both of these groups of bac- 
teria are frequently found on tlie sMn and on blood 
agar plates exposed to the air. 

Esch, coli, P, vulgaris and Ps. aeruginosa are most 
commonly found in the intestinal tract and are there- 
fore frequently picked up hy the hands of doctors and 
nurs^. They are occasionally found on plates exposed to 
the air hut not as freauentlv as the other organisms. 


Minimizing Contamination of the Opera- 
tive Wound. It would seem that the chief 
sources of contamination arc, in the order of 
their importance: (1) the skin of the patient, 
(2) the noses and throats of persons in the 
operating room, (3) the hands of the operat- 
ing personnel, (4) the air of the operating 
room and (5) the instruments and materials. 

1. Contamination from the skin of the patient may 
be minimized, but with our present knowledge it can- 
not be entirely prevented. No antiseptic yet devised 
is able to destroy all of the bacteria deep down in the 
hair follicles and sebaceous glands. During the op- 
eration, some of these are undoubtedly cast out in the 
secretion of the skin glands. When the scalpel cuts 
through the skin, it carries some of these organisms 
into the wound. If the cautery knife is used to make 
the incision and if the edges of the skin are then fas- 
tened with Michel clips to towels, these sources of 
contamination will he reduced. Sterilization of the 
skin seems to he the weakest link in the chain of 
sterile technique, and careful search should he con- 
tinued for a more penetrating and more effective anti- 
septic. In our laboratory Kraissl and Cimiotti experi- 
mented on the skin of rabbits with all the advocated 
^ including iodine (alcohol and water- 

soluble), Mercurochrome, Metaphen, Merthiolatc, 
acriflavine, gentian violet, methyl violet and brilliant 
green hexylresordnol, sodium hypochlorite, Zephiran 
and Azochloramid, When hits of skin are snipped out 
after coritact with these preparations, water-soluble 
iodine solutions consistently give the highest percent- 
age of sterile cultures, hut even iodine does not give 
more than 60 to 70 per cent sterility, leaving much to 
be desired. 

One drawback to the use of iodine is a tendency to 
burn the skin of patients with red or hlonde hair, 
particularly if it is applied to creases or folds of the 
skin from which it does not evaporate. From such skins 
It should he vvashed off with alcohol after a five-minute 
contact. In 1944 a new skin antiseptic, diphenyldihy- 
drohexachloromethane, commonly known as G. 1 1 was 
incorporated into a soap solution in 1 to 2 per cent 
roncentration. A five-minute scrubbing o£ tbe skin with 
this preparation gives a higher percentage of sterile 



45 


Relationship of Bacteriology to Surgery 


cultures from skin snips than does iodine. In many 
clinics this has replaced iodine for skin preparation. 

2. Contamination of the wound hy organisms from 
the nose and throat may be minimized by completely 
covering the nose and mouth with an impermeable 
mask or a four-ply, fine-meshed gauze mask which 
will catch the droplets which are invariably expelled 
during coughing, talking or breathing. A helmet should 
cover the head and neck. This will serve to divert air 
currents during expiration down into the gown. These 
currents might otherwise carry bacteria around the mask 
and on to the sterile field. 

3. Contamination from the surgeon's hands may be 
minimized hy prolonged scrubbing with soap and hot 
water to remove the top layers of keratinized skin and 
the accompanying bacteria and then by washing in an 
antiseptic solution. It has been demonstrated that a 
mixture of chloride of lime and sodium carbonate is 
effective for this purpose. 

G. 11 soap has also been advocated for the sterile 
“scrub-up” procedure for the surgeon's hands. The 
results seem to indicate that the bacterial flora of the 
hands is rapidly reduced by a brief period of contact. 
What is more important, the count does not increase 
under the gloves during the period of the operation. 

4. Contamination from the air may be minimized 
by limiting the number of persons entering the op- 
erating room before as well as during the operation; 
by minimizing the opening and closing of doors and 
the activity within the room during the operation; by 
covering as much of the sterile field as possible with 
canopies; by covering the hair, the nose and mouth 
and the feet of all those who enter the operating 
room; by filtering the air, either before it enters the 
room or by circulating it through a filter in the room; 
by having as few as possible dust-collecting objects in 
the operating room, and by frequendy cleaning the 
walls, ceiling and floor. Studies by Wells and also 
by Hart demonstrated the possibility of minimizing 
air contamination by the use of ultraviolet radiation in 
the operating room. Suitable apparatus is now avail- 
able which releases a high percentage of rays from 
the bactericidal zone of the ultraviolet spectrum, the in- 
tensity of which can be accurately measured. Kraissl, 
Cimiotti and Meleney showed that effective inten- 
sities can be obtained which are not injurious to the 
tissues but which will reduce air contamination to 
one-tenth or one-twentieth of the amount normally 
found in the operating room, 

5. Contamination from autoclaved supplies should 
be absolutely prevented. If an adequate vacuum is 
used before the steam is introduced, there should be 
no difficulty in destroying all bacteria (fifteen min- 
utes' vacuum and forty-five minutes' sterilization at 
from 18 to 20 pounds of pressure is a safe standard). 
If less time is given for the preliminary period of 
evacuation, a longer time will be required for sterili- 
zation. The timing device invented by Walter for 
keeping the autoclave locked until sterilization is 
complete is an added safeguard which is of consider- 
able value. The boiling of instruments is, perhaps, 
the most efficient method of killing the bacteria on 
them, and if sufficient time is given — from five to 
ten minutes — one need have no fear of contamination 
from these sources. A few pathogenic strains of spore- 
forming organisms have been reported on which will 
resist boiling for fifteen to twenty minutes or longer, 


hut for all practical purposes the time just mentioned 
wull he adequate. Sharp instruments, such as knife 
blades, scissors and needles, are generally and prop- 
erly sterilized hy prolonged soaking in a noncorro- 
sive antiseptic, such as the Bard-Parker solution. In- 
struments and sponges constantly transfer into the 
wound organisms which have dropped on them from 
the air or which have been transferred from other 
contaminated objects. They thus act as secondary 
rather than primary sources of contamination. 

ESTABLISHED SURGICAL INFECTIONS 

Definitions. Infectious diseases are those 
disorders of the animal body resulting from the 
entrance of microorganisms into the tissues 
where they can live, grow, multiply, and carry 
on their metabolic processes. Surgical infec- 
tions are those which, according to the best 
medical opinion, should be treated by opera- 
tive means. The factors which make an in- 
fectious disease amenable to surgical therapy 
depend on whether the lesion is likely to re- 
solve spontaneously or is likely to produce 
necrosis of tissue or a localized collection of 
purulent exudate which can be excised, incised 
or drained with relatively little harm to the 
body as a whole. If, with a minimum of injury, 
the whole or a large part of the focus of infec- 
tion can be removed, a surgical procedure is 
warranted, but the good that is accomplished 
must outweigh the harm that is done. For ex- 
ample, an acutely inflamed appendix, a chron- 
ically infected gallbladder or a pyonephrosis 
may be excised; an abscess of a lymphatic gland 
may be drained, and cellulitis of the neck 
which will probably produce edema of the 
glottis may be incised. On the other hand, sur- 
gical procedures are not warranted if the infec- 
tion is one which ordinarily subsides spon- 
taneously, such as pneumonitis or phlebitis; if 
it is one which responds to medication, as, for 
example, a syphilitic lesion, or if it is one which 
yields to rest and sunshine, like certain tuber- 
culous processes; or if there has been little 
destruction of tissue, as in a low-grade celluli- 
tis, or if the process is generalized, as in miliary 
tuberculosis. Similarly, if the lesion is inac- 
cessible because of intervening parts, as in 
bronchial lymphadenitis, or because its exact 
location is not known, as in many cases of sep- 
ticemia, or because it involves some essential 
organ, such as the valves of the heart, surgical 
procedures in their present stage of develop- 
ment are contraindicated because they would 
do more harm than good. Organisms producing 
lesions in the body which warrant surgical 



46 Chapter 3. Surgical Bacteriology, Chemotherapy and Antibiotic Therapy 


treatment are those which either cause local 
death of tissue or cause the exudation of leuko- 
cytes in large number, in other words, necrotiz- 
ing or pyogenic organisms. 

Since the availability of the antibiotics, a cer- 
tain number of infections that would have 
resulted in the breakdown of tissue (and may 
therefore be called surgical infections) arc 
brought under control by either the systemic 
or the local administration of an antibiotic and 
a surgical procedure is obviated thereby. 

Organisms Producing Surgical Infections. 
Most of the microorganisms which have been 
found to exist in nature are of little concern to 
those who are solely interested in human in- 
fectious diseases. A great host of organisms, 
however, are of vital interest because they 
make life possible by completing the cycle of 
physical and chemical processes which cause 
the disintegration of dead animals and plants 
into the simple chemicals which plants require 
for their own synthesis. The plants are in turn 
consumed by and make possible the growth of 
animals and man. Of the relatively small group 
of bacteria which are pathogenic for man, a still 
smaller number produce surgical diseases. 
These will be considered in the following 
order: 

I. Aerobic bacteria. 

A. Aerobic cocci. 

(I) Gram-positive. 

(A) Streptococci. 

1. hemolytic. 

2. nonhemolytic. 

(B) Micrccoccus pyogenes (Staphy- 

lococci) . 

1. var. aureus, 

2. var. albus. 

(G) Pneumococci. 

(II) Gram-negative. 

(A) Gonococci. 

B. Aerobic bacilli, 

(I) Gram-positive 

(A) Mycobacterium tuberculosis. 

(B) B. anthracis. 

(G) Corynebacterium diphtheriae. 

(D) Diphtheroid bacilli. 

(E) B. subtilis. 

(II) Gram-negative, 

(A) Escherichia coli. 

(B) Salmonella typhosa. 

(C) Klebsiella pneumoniae. 

(D) Peseudomonas aeruginosa. 

(E) Proteus vulgaris. 

(F) Hemophilus influenzae. 

(G) Malleomyces mallei. 

, Anaerobic bacteria. 

A. Anaerobic cocci. 

(I) Gram-positive. 

(A) Streptococci. 


B. Anaerobic bacilli. 

(1) Grain-positiv<‘ clostridia. 

(A) CL perjiingcns. 

(B) bV, novyi. 

(G) CL srptiami, 

(D) Cl, sunk! Hi. 

( E ) Cl. (elani. 

(ID Gram-negative. 

HI. Microaerophilic organisms. 

A. Streptococci. 

(I) hemolytic. 

(II) nonhemolytic. 

IV. Spirochetes. 

V, Higher microorganisins. 

A. Actinomycete.s. 

B. Blastomycetcs. 

G. Coccidioides. 

D. Sporolricha. 

In the following paragraphs a brief account 
is given of the surgical infections etiuscd by 
these various organisms. !Ar the morphologic 
and cultural characteristics of these bacteria 
the reader is referred to textbooks of bacteri- 
ology. 

I. AEROBIC BAC'I'EIUA 
A. AEROBIC COCKU 

(I) Gram-Positive Coed. (A) Streptococci 
The only significant division of this group is 
based on the lytic action of the organism on 
red blood cells. Streptococci which produce 
hemolysis are in general of considerable viru- 
lence, and those which do not arc relatively 
avirulent. 

1. Hemolytic Streptococci. Previous to 
1935 hemolytic streptococci were the cause of 
most of the fulminating cases of "blood poison- 
ing.’’ The discovery and rapidly spreading use 
of the sulfonamides and the antibiotics, how- 
ever, have not only saved many patients with 
septicemia who otherwise would have died, 
but the control of local infections clue to this 
organism, in the early stages, has in recent 
years often prevented the development of sep- 
ticemia. This has rendered infections with 
hemolytic streptococci less menacing tlian for- 
merly, and the nonhemolytic varieties, less well 
controlled by these agents, have become rela- 
tively more important. They arc jTe.qjagntly 
fetin d^ in the throats of perso ns, espe- 

dunh^Tlie " early. ..spring 
widely dis^inated from that 
source so that many persons acquire the or- 
ganisms when in crowded places and pass them 
on to others through the medium of hand- 
kerchiefs, hands or droplets discharged from 
the nose or mouth with br ca t hi ng j g h yn g - 



47 


Relationship of Bacteriology to Surgery 



Figure L a, Staphylococci from hroth culture, X 1500; h, hemolytic streptococci from hlood hroth culture, 
X 1400; Cf round-end spore-forming gram-positive bacillus; Cl. tetani from old cooked meat culture medium, 
X 1400; d, aerobic oval spore-forming gram-positive bacilli; B. anthracis from agar slant, X 1400, (Meleney; 
The Bacteriological and Immunological Aspects of Surgery, in Nelson’s Loose-Leaf Surgery.) 


Streptococci probably do not live for a long 
time outside the animal body, but when they 
are fairly directly transferred from one human 
environment to another, small numbers are able 
to produce disease. 

Hemolytic streptococci enter the body most 
often through a n accidental v^ound , such in- 
fections being much more frequent in the later 
winter and early spring than at other times of 
the year. Just how the organisms live, grow and 
spread in such a wound will be discussed later. 
Suffice it to say here that they usually produce 
cel lulitis in such wounds and freque ntly cause 
,1ympE^^;itis^lymplia^erii ^^ 
mtis and^sejptiDemia; orTHey may very rapidly 
produce extensive gangrene of the skin. When 
streptococci persist in the blood stream because 
of the presence of an overwhelming distribut- 
ing focus of infection, they may settle in the 
spleen, liver, kidiiey^pr ^ 

TooffinTZanS"^ other meta static abscesses. 
In children -they-.frequently^^^^ in. joints, 
particularly the hip joint or in tBFneighboring • 
epiphyses. , 


Hemolytic streptQQQCcl.mayJnvade the body 
through the thr^^at and tonsils and spread to the 
cervicar~lympH they produce 

a3i nihTl ^ich~Ts~"Tr eg uently accompanied by 
nigh fever and profound intoxication. Such an 
itifectlon may persist for weeks, for the glands 
are slow to resolve or slow to liquefy and form 
an abscess. The organisms may produce diffuse 
cellulitis of the neck which may spread to the 
glottis and by a rapidly developing edema 
threaten suffocation. Hemolytic streptococci are 
frequently found in cases of acute peritonitis. 
Usually in such instances there is a history of 
previous upper respiratory infection. It is pos- 
sible to cultivate the organisms from the blood 
in many of these cases. Hemolytic streptococci 
may also enter the body through the lungs, pro- 
ducing pneumonia and suppurative pleurisy 
Hemolytic streptococci are by far the most 
common organisms in suppurative tenosynovi- 
tis. They are almost always introduced through 
a wound of the tendon sheath, such as is made 
hy a pin-prick through a flexion crease. 

The clinical manifestations of the different 


48 Chapter 3. Surgical Bacteriology, Chemotherapy and Antibiotic Therapy 



Figure 2. a, Colony of gram-negative bacilli in the wall of the bladder; Klebsiella pneimoiiiae, X 1400; 
h, colony of staphylococci in the prostate gland, X 1400; c, masses of staphylococci in an infected thrombus; 
d, colony of Cl perfringens in striated muscle. One oval spore is seen. (Melency; The Bacteriological and 
Immunological Aspects of Surgery, in Nelson’s Loose-Leaf Surgery.) 


diseases produced by the hemolytic streptococci 
are so varied that many attempts have been 
made to find some cultural or biologic activity 
to account for the differences, but most of these 
artificial classifications have been without clin- 
ical significance, with the exception of Lance- 
fields. She has been able to place almost all of 
the pathogenic strains from human sources in a 
single group by the employment of a precipitin 
test. Apparently the differences depend not so 
much on the particular type of hemolytic strep- 
tococcus as on the portal of its entry into the 
body and the resistance or susceptibility of the 
local tissues of the host. 

2. Nonhemolytic Streptococci. In the 
production of surgical infections there is little 
difference between the streptococci which form 
green colonies on blood agar plates and those 
which have no effect on the red cells. Such or- 
ganisms produce lesions which are even more 
varied in their clinical manifestations than 
those produced by the hemolytic streptococci. 
They are usually associated with the respiratory 


or intestinal tract. Nonhemolytic streptococci 
ar^ normaTTnbabitants of the mouth and arc 
present but are less numerous in Ifie nasaljxis- 
sages. They are frequently the chief (ilfendcrs 
in the formation of abscesses around the teeth 
or of abscesses in the cervical lymph glands 
following dental infections. They arc appar- 
ently able to resist the destructive action of the 
gastric juice, for they are frequently present in 
the upper duodenum; and when a perforation 
develops in that portion of the intestinal tract, 
they are frequently found in pure culture in 
the peritoneal exudate. Xhoy^are* present in the 
intestinal tract in increasing numbers from 
abd?e*“ downward and are commonly found in 
the peritoneal exudate when the appendix per- 
forateTThey may occasionally pass tlirough* an 
inflamed appendix wal] . .without perforation. 
They are found in Targe numbers in the exu- 
dates in cases of ulce]:aliv:^colte but it has 
not been proved th^they ar? tKe etiologic fac- 
tors. Similarly, it has been claimed that they 
produce gastric and duodenal ulcers, hut the 


49 


Relationship of Bacteriology to Surgery 


evidence is not clearcut. They may frequently 
be cultured from the contents or the wall of an 
inflamed gallbladder and share with Escher- 
ichia coli and Salmonella tyfhosa the responsi- 
bility in the production of infectious cholecysti- 
tis and cholelithiasis. In association with Escher- 
ichia coli they may also produce liver abscess es. 
Apparently they have a symhi6tic~roIe in the 
severe infection known as Vincents angina, in 
which the spirochetes and fusiform bacilli from 
the mouth play an active part. Likewise, they 
are frequently found in infections which follow 
animal bites or human bites. Like the hemolytic 
variety they may contaminate accidental 
wounds and cause infections in them. 

(B) Staphylococci (Micrococci). Surgical 
infections caused by staphylococci are morejiu- 
mer^s than those caused by streptococci,, but 
in general they are less serious. Staphylococci 
have been significantly classified according to 
their pigment formation and less significantly 
according to their power to hemolyze blood. 
Most pathogenic staphylococci give a positive 
coagulase test. 

Staphylococci are more resistant to control 
with the sulfonamide drugs than are the hemo- 
lytic streptococci, but the two groups are both 
susceptible to several of the antibiotics. 

1. Micrococcus pyogenes yar. aureus 
(Staphylococcus aureus). Organisms of 
this type are found commonly on the skin and 
may be able to live and grow in the ducts of the 
sweat and sebaceous glands. They are fre- 
quently present in the nasal passages but more 
rarely in the mouth and alimentary tract. Ap- 
parently they can survive for a long time on 
dust particles in the air. They produce a yel- 
lowish brown pigment in the colony when 
grown on solid artificial media and vary con- 
siderably in their hemolysis on blood agar 
plates. Most of the pathogenic strains are co- 
agulase positive and ferment mannitol Micro- 
coccus pyogenes var. aureus is the common 
organism present in the localized inflammatory 
processes of the skin, such as furuncles and car- 
buncles. It occasionally produces an abscess 
around a tooth and is almost the sole cause of 
suppurative parotitis. Rarely, yellow micrococci 
enter the body through the lungs and produce 
pneumonia and empyema, but this is usually a 
sequela of septicemia. They exceed streptococci 
in the frequency of causing clean wound infec- 
tions, probably because they are invariably in- 
troduced from the surface of the skin itself. 


There is no seasonal incidence of micrococcic 
infections as there is with streptococcic infec- 
tions. From infected wounds they frequently 
spread via the veins or lymphatics into the gen- 
eral circulation and produce septicemia with 
metastatic abscess in various organs or tissues 
of the body. In such cases either suppurative 
‘thrombophlebitis of the small vessels in the 
v;all of the local lesion or in the neighboring 
veins or lymphatics, or vegetative endocarditis 
is usually found at autopsy. Micrococci seem 
to have a special predilection for bone, espe- 
cially in young children. They may enter the 
body through a pimple or a trivial wound and 
produce a violent reaction, resulting in exten- 
sive destruction of the bone marrow cavity. 

2. Micrococcus pyogenes var. albus 
(Staphylococcus albus). These organisms 
produce white colonies on agar plates which 
may or may not be hemolytic. They are exten- 
sively distributed in nature, being found in the 
same localities on and in the human body as 
Micrococcus pyogenes var. aureus. Usually the 
lesions produced by them are milder than those 
caused by the yellow micrococci. They are usu- 
ally coagulase negative and fail to ferment 
mannitol. These organisms are most frequently 
found in small pimples and boils and in the 
trivial infections which occasionally occur in 
clean operative wounds. They rarely produce 
septicemia or osteomyelitis. 

(C) Pneumococci. The surgical diseases 
produced by this group of organisms are gen- 
erally associated with either a pleural or a 
peritoneal infection. With less rapidity than 
the streptococci, these organisms pass through 
the lung and infect the pleural exudate which 
develops to a variable degree in practically all 
cases of pneumonia. Frequently, this pleural 
exudate remains sterile, but if pneumococci 
can be cultured from it, the condition generally 
develops into a surgical rather than a medical 
problem. Then a careful study of the individual 
case is required in order to decide whether and 
when to use surgical measures for relief. From 
the pleura, pneumococci may spread to the 
pericardium and there produce a suppurative 
process which will require surgical therapy. 
When the organisms invade the blood stream, 
they not infrequently localize in the joints or 
in the meninges. The former condition requires 
surgical treatment, and the prognosis is good, 
but localization in the meninges was, previous 
to the advent of the sulfonamides, almost in- 



50 Chapter 3, Surgical Bacteriology, Chemotherapy and Antibiotic Therapj 


variably fatal. These drugs were soon found to 
have an almost miraculous curative effect on 
pneumococcic infections not only of the lungs 
but of the meninges. The pneumococcus is 
even more susceptible to certain of the anti- 
biotics than to the sulfonamides. These anti- 
biotics must be given intrathecally in order 
that they may control meningeal infections. 

Surgeons are particularly interested in pneu- 
monitis following an operation. This is more 
likely to occur in a patient who has recently 
had a cold than in one who has not. It is also 
more common following upper than lower ab- 
dominal operations. Apparently a number of 
factors— mechanical and chemical as well as in- 
fectious— are at play in the production of these 
lesions. Frequently a plug of mucus blocks a 
bronchus and produces an atelectatic area, 
which becomes susceptible to bacterial infec- 
tion. The lack of aeration in the bases of the 
lungs, due to pain on deep breathing after an 
upper abdominal operation, favors the closure 
of the small bronchi in the lower lobes. Cutler 
and Hunt stressed the importance of the role 
of emboli which come from the operative field 
and produce small pulmonary infarcts which 
are subsequently infected. The importance of 
postoperative pneumonia has appreciably de- 
creased since the advent of the sulfonamides 
and the antibiotics. 

Since pneumococcic infection of the peri- 
toneum is four times as prevalent in females 
as in males, the fallopian tubes have been con- 
sidered to be the portals of entry. However, 
some of these cases follow frank pneumonia, 
and then the source of infection is almost cer- 
tainly extragenital. Occasionally an ovarian cyst 
becomes infected with pneumococci. Here the 
portal of entry is uncertain. 

(II) Gram-Negative Cocci. (A) Gono- 
cocci. The activity of these organisms comes 
within the scope of surgery largely through 
errors in diagnosis. Operations are often per- 
formed in cases of acute peritonitis, suppura- 
tive arthritis, suppurative tenosynovitis or 
epididymitis because it is impossible to tell, 
before a culture of the exudate has been made, 
whether the infectious agent is the gonococcus 
or some other organism. Since gonococcal le- 
sions usually subside spontaneously, these op- 
erations are futile and probably harmful, al- 
though in many instances they are justifiable. 
The response of these infections in both acute 
and chronic forms to the sulfonamides and the 


antibiotics lias largely taken them out of the 
field of surgery. 

n. AHROIHC BACILLI 

(I) Gram-Positive Bacilli. CA) Mycohae- 
terhim tiibcrculosh. From a surgical point of 
view Mycohacterimn tuberculosis is by far the 
most important of the aerobic bacilli. It may 
attack any organ or tissue of the body and in 
that respect is more ubiquitous than any other 
organism. Fortunately, in the United States, 
surgical tuberculosis has gradually become 
more and more rare as a result of improved 
hygienic conditions and an appreciation by the 
patient, developed by popular education, of 
the importance of treating the disease in its 
early stages. 

The tubercle bacillus usually enters the 
body through either the respiratory or the 
alimentary tract and frequently lodges in the 
cervical and mesenteric lymph glands. In the 
former instance the tonsils arc frequently found 
to be infected and require surgical removal. 

Milk as a source of the bovine type of 
tubercle bacillus has been practically eliminated 
in many states by the testing of herds and the 
destruction of tuberculous cattle. 

Thirty-five years ago it was common surgi- 
cal practice to remove tuberculous cervical 
lymph glands by excision. Today this proce- 
dure is required in a much smaller number of 
cases, chiefly because the disease occur.s less 
often but also because some cases respond 
favorably to x-ray treatment or to heliotherapy. 
Tuberculosis of the mesenteric lymph glands 
occasionally necessitates surgical removal, par- 
dcularly when the glands become calcified and 
incapacitate the patient because of continued 
severe abdominal pain. Pulmonary tuberculosis*" 
has, however, come within the scope of surgery 
because of the successful work of Sauerbruch 
in Germany and a number of other surgeons 
in Europe and America. A plastic operation is 
performed on the chest which permits the 
diseased lung to collapse and enjoy more or 
less complete physiologic rest. JLobcctomy or 
pneumonectomy may be the operation of choice 
if only one lobe or one lung is involved in care- 
fully selected types of cases. Progress in this 
field is well shown by comparison of the re- 
sults obtained by the pioneers and recent 
workers. 

Tuberculosis of the intestinal tract is gen- 



51 


Relationship of Bacteriology to Surgery 

erally limited to tlie lower ileum and cecum, are common inhabitants of the intestinal tract 
but other portions of the tract may be involved, and are found in peritoneal exu ates w en 
These cases occasionally require excision or there has been intestinal perforation, cca 
short circuiting, but many of the patients re- sionally these organisms seem to e a e to 

spond to a prolonged hygienic regimen, includ- produce a trivial infection in ^ clean operative 

ing rest and heliotherapy. wounds and may grow out in pure cu ture 

Tuberculosis of the peritoneum frequently when the other contaminating organisms tail 
becomes a surgical problem, usually because to do so. • c i, 

of the difficulty of making a differential diag- (E) Bacillus subtilis. This is of the same 

nosis. Often it cannot be distinguished from significance to surgeons as the diphtheroid ba- 
other diseases accompanied by ascites, partic- cilli, except that it is not often found in 
ularly cancer, unless an exploratory operation peritoneal exudates. It is^ a sporedormmg or- 
is performed. If the focus is abdominal and ganism of low pathogenicity which may be 
can be removed without great risk, such a pro- used satisfactorily as a test organism iti e 
cedure is justifiable. Tuberculosis of the genito- termining the efficacy of any sterilization 
urinary tract is usually secondary to foci process. _ . rt 

elsewhere. Frequently, however, the primary (II) Gram-Negative Bacilli. Gram-nega- 
focus is small or quiescent, and it may be wise five bacilli have become increasingly important 
or urgently necessary to remove the secondary in recent years since penicillin has been avail- 
focus. This is often a relatively safe and sue- able for clinical use. Many of the gram-nep- 
cessful procedure in tuberculosis of the kidney, live organisms produce a substance called 
but it is more difficult in tuberculosis of the penicillinase, which renders the penicillin m- 
epididymis or of the bladder. active and when present in a mixture of hac- 

Tuberculosis of bones and joints is still fairly teria, as in burns or accidental wounds, may 
common in children. It is, of course, hemato- interfere with the therapeutic effect of peni- 
genous in origin and must therefore have a cillin. 

primary focus elsewhere. Surgical fixation of (A) Escherichia coli. These organisms lep- 
such lesions is frequently indicated. resent one of the most widespread groups d 

(B) Bacillus anthracis. This was the first bacteria. They are found almost universally 

organism discovered to bear a specific relation- in the intestinal tracts of man and animals, 
ship to an infectious disease. It gains entrance appearing in the stools shortly after birth and 
to the human being by direct inoculation of remaining there throughout life. As long as 
the skin and occurs most commonly in those they remain within the intestinal tract, they 
who handle hides, hairs, bristles and wool. A apparently do no harm to the host. Hovvever, 
carhuncle-like lesion rapidly develops and is when they are introduced into other tipues 
associated with severe constitutional symptoms, and organs, they may cause profound illness 
B. anthracis infections are amenable to anti- and death. With the constant trauma to the 
biotic and sulfonamide therapy. mucous membrane of the intestips from in- 

(C) Corynebacterium diphtheriae. This digestible food, particularly in the appendix 

microorganism is of interest to the surgeon only and in the lower sigmoid and rectum, whpe 
because, at times, it may be found as a con- the feces are inspissated, the door is open foi 
taminating organism in wounds and chronic the entrance of these organisms into the deeper 
ulcers which fail to heal. Grossmann examined tissues. Thus, Esch. coU may be carried to the 
four hundred open wounds and found the true neighboring lymph glands or to the liver. From 
diphtheria bacillus in 5 per cent of them. Some the liver it may be carried to the gallbladder by 
of the wounds healed promptly after the ad- way of the bile, or it may reach the gallbladder 
ministration of diphtheria antitoxin. by passing up the choledochus. Being dis- 

(D) Diphtheroid Bacilli. These bacilli con- charged in large numbers with the stools, it 
stitute a heterogeneous group of gram-positive naturally contaminates the area around the 
orcranisms. They are pleomorphic, often becom- anus and frequently may be introduced irito 
ing coccoid or assuming bacillary forms which the vagina and urethra of females, esppially 
vary considerably in size and shape. They are infants. Owing to the difficulty of sterilizing 
frequently found in the air and occasionally these parts, it is almost invariably introduced 
on the skin and in swollen lymph glands. They into the bladder during catheterization, and 



52 Cfiapter 3. Surgical Bacteriology, Chemotherapy and Antibiotic Therapj 


it is the commonest organism found in either 
the spontaneous or postoperative cases of 
cystitis and pyelitis. 

Escherichia coll is of interest to the surgeon 
chiefly because of its association with appendi- 
citis and cholecystitis. It may not be the pri- 
mary cause of appendicitis, but when the organ 
becomes inflamed, Esch. coli may pass through 
the grossly intact wall, produce peritonitis and 
be recovered from the exudate in pure culture. 
The other intestinal organisms seldom do this, 
but if perforation takes place, some representa- 
tives of all of the bacterial species present 
in the intestinal tract are discharged into the 
peritoneal cavity and may play a part in the 
subsequent infection. In like manner, when 
the intestinal wall is perforated by any ulcer 
or by a foreign body, Esch. coli plays a major 
role in any subsequent infection. If the or- 
ganisms then spread via the portal venous 
radicles to the liver, multiple abscesses may 
form. Esch. coli reaches the gallbladder either 
from the liver via the bile or by passing up the 
duct. It may precede or follow the develop- 
ment of stones, but it usually shares with Sal- 
monella typhosa and the nonhemolytic strep- 
tococcus the infective role in the development 
of cholecystitis. 

(B) Salmonella typhosa. This is of interest 
to the surgeon chiefly because of its relation- 
ship to certain complications of typhoid fever. 
The chief of these are perforations of the in- 
testine and cholecystitis. Occasionally subperi- 
osteal abscesses appear in the long bones, and 
more rarely abscesses develop in the subcutane- 
ous tissue elsewhere. 

Ulcerations of the intestines leading to perforations 
are almost certainly due to the inflammatory process 
in Peyer’s patches of the lower ileum. When perfora- 
tion takes place, not only the typhoid bacillus but all 
of the intestinal organisms are introduced into the 
peritoneal cavity. In such cases, only prompt opera- 
tion and closure of the perforation will prevent death. 
Frequently during the course of typhoid fever the 
patient complains of symptoms in the region of the 
gallbladder, hut in many cases there are no subjec- 
tive signs until years afterward, when the mechani- 
cal factor of gallstones calls attention to the fact that 
a pathologic condition is present. In such cases the 
typhoid bacilli may be found in the stool, but they 
usually disappear after removal of the gallbladder. 
In a few cases the organism establishes itself penna- 
nendy in the liver or in the intestinal tract, and the 
patient remains a carrier and a menace to society for 
life. 

Kleh Stella pnewmonioB, Origin all y this 
bacilltis was thought to be the chief cause of 


lobar pneumonia, but its occurrence in sudi 
cases is rclati\'el\’ rare. Its cliicf interest to the 
surgeon is due to the fact that it causes serious 
complications in certain diseases of the respire 
tory and alimentary tracts, linqn’cnia or abscess 
of the lung in which tiiis organism is found in 
almost invariably serious. 'I liis organism is 
rarely found alone in peritoneal c.xudatcs, but 
when perforation has occurred and the organ- 
ism has established itself with others in the 
peritoneal cavity, it stubbornly resists all efforts 
to eradicate it. Not infrequently, it is carried 
off to the liver, and there it produces one or 
more abscesses which arc almost always fatal 

(D) Pseudomonas ncrug/nosu. I’his organ- 
ism is ordinarily considered to l)e nonpatho- 
genic, but it frequently is most annoying as a 
secondary contaminant in chronic infections, 
especially those associated with the alimentary 
canal, in which it is common!}' found. The 
characteristic appearance and odor of the green 
pus indicate its presence and demand special 
measures to insure its removal. It is often ex- 
tremely resistant to eradication and occasionally 
invades the deeper tissues. It has frec|ucndy 
been found in the blood stream. In such cases 
it rarely, if ever, produces metastatic foci and 
generally disappears from the blood when vigor- 
ous efforts arc made to remove it from the 
portal of entry. When it occurs in a ]>ost- 
operative infection in a previously clean wound, 
a serious complication usually results (Table 1). 

(£) Protem vidjiaris. This bacillus is fre- 
quently associated with chronic infections in 
the neighborhood of the alimentary canal, espe- 
cially gangrenous processes. Some investigators 
have insisted that it is the cause of such infec- 
tions, but it is usually merely a secondary 
invader. A few authentic cases have been re- 
ported, however, in which it was truly patho- 
genic. In one of the author’s cases it produced 
a thrombophlebitis of the jugular vein in the 
peritonsillar region. The clot propagated itself 
back to the brain, an abscess formed and the 
process spread with the blood stream as well, 
producing an abscess of the lung. 

(F) Hemophilus influenzae. The role of 
this organism in infectious diseases, particu- 
larly of the respiratory tract, is still a moot 
question, but a few authentic cases make it 
necessary for the surgeon to remember that the 
organism may at times produce suppurative 
pleurisy which requires surgical attention. 

(G) Malleomyces mallei With disappear- 
ance of the horse from ^ 



Relationship of Bacteriology to Surgery 53 


man, the surgical significance of M. mallei has 
steadily declined. The surgeon must remember, 
however, that this organism can produce serious 
lesions of the skin and of the subcutaneous 
tissues resembling the lesions of staphylococci 
or of anthrax, which may be either extremely 
chronic or exceedingly acute and fatal. 

II. ANAEROBIC BACTERIA 

Pasteur made the observation in his early 
bacteriologic studies that certain organisms 
grow only in a medium from which the air 
has been excluded. Such organisms were called 
anaerobic bacteria, and it was assumed that 
oxygen was deleterious to their existence. 

A. ANAEROBIC COCCI 

The only strictly anaerobic cocci of interest 
to surgeons are grain-positive nonhemolytic 
strep tocci which are occasionally found in 
putrefactive processes in the intestinal tract, 
occasionally in foul infections around the teeth 
and tonsils and in foul lung abscesses. These 
organisms are not infrequently the cause of 
puerperal fever and may produce fatal septi- 
cemia. They are occasionally found in liver 
abscesses and in chronic brain abscesses. They 
are generally of low virulence and may not be 
capable of producing disease except in symbiosis 
with other organisms or when there has been 
a necrosis of tissue from trauma or from the 
absence of blood supply. 

They fall into two main groups—those which 
produce a foul odor and gas in artificial media 
and those which do not. Prevot has attempted 
a classification of these organisms, but the whole 
group needs further careful study. 

These organisms are very susceptible to zinc 
peroxide if it can be brought in contact wdth 
them by local application. Several of the anti- 
biotics are generally effective in the treatment 
of infections produced by these bacteria. 

B. ANAEROBIC BACILLI 

Under this classification there are five species 
which are of importance to the surgeon. Four 
of them make up the gas gangrene group, and 
the other is the tetanus bacillus. Each of these 
organisms produces a powerful exotoxin which 
may be specifically neutralized by the appro- 
priate antiserum. 

(I) Gram-Positive Anaerobic Bacilli. Prac- 
tically all of the important gram-positive an- 



Figiire 3. Muscle fibers destroyed by the action 
of gas gangrene organisms. Note the paucity of 
leukocytes. 


aerobic bacilli are spore-forming organisms and, 
because of this characteristic, have been given 
the generic term of ^'Clostridia” by the nomen- 
clature committee of the Society of American 
Bacteriologists. 

{A) Clostridnm perfringens. By far the 
commonest and most important is the Bacillus 
aero genes capsvlatus of Welch and Nuttall, 
now called Clostridium welchii or Clostridium 
perfringens. It is the common cause of the gas 
gangrene which reached such enormous pro- 
portions in World War 1. This organism is al- 
most universally present in the intestinal tract 
of man and of most animals, just as is Esch. 
coli, but because it forms spores, it survives 
longer outside of the body and remains for a 
long time in fertilized soil. The filth of trench 
life and the frequency of contamination of 
gunshot wounds with soil and woolen clothing 
make it readily understandable why gas gan- 
grene was so common among the wounded in 
World War I In gunshot wounds this organ- 
ism was frequently found when there was no 
evidence of its activity, and it must be con- 
sidered to be essentially a saprophytic organism 
which becomes pathogenic only under cer- 
tain conditions, namely, when it has been in- 
troduced in large numbers, when foreign bodies 
are present or when there has been consider- 


54 Chapter 5 . Surgical Bacteriology, Chemotherapy and Antibiotic Therapy 


able destruction of tissue, particularly muscle, 
which offers it a favorable environment for 
growth and toxin production. 

In civilian life, compound fractures arc the 
precursors of a large proportion of the cases of 
gas gangrene because of the usually extensive 
injury to muscles and the contamination of 
the depths of the wound with street dirt. 

Clostridium perfringens is also of some im- 
portance in peritonitis. It rarely passes out 
through an intact intestinal wall, but if there 
has been a perforation which has permitted 
the escape of intestinal contents, it is able to 
maintain itself in the peritoneum, although its 
significance there is not so great as when it is 
actively growing in muscle tissue. An infection 
with this organism is characterized by pro- 
found intoxication— high fever, rapid pulse, 
prostration and apprehension. Locally there is 
pain in the wound, redness, swelling, bronzing 
of the skin and crepitation, which is due to the 
generation of gas by the action of the organ- 
ism on muscle tissue. The extent of the bubbles 
of gas in the tissues may be accurately deter- 
mined by taking a roentgenogram of the af- 
fected part. When the infection has become 
established, it travels with great rapidity up 
the muscle bellies, and unless surgical extirpa- 
tion is promptly applied, with the aid of potent 
antibiotics and serum therapy, the patient will 
almost certainly die. 

(B) Clostridium novyi, (C) Clostridium 
septicum and (D) Clostridium sordelUi. 
These clostridia may be listed together as the 
other gas gangrene organisms. They can be 
readily distinguished from CL perfringens by 
their cultural characteristics and by their neu- 
tralization with specific antitoxin. They all 
produce gas gangrene and are frequently pres- 
ent with CL perfringens in severe war wounds. 
In the African campaign of World War II, 
MacLennaii found an unusually high propor- 
tion of CL novyi in the wounds sustained by 
the British forces. When these organisms are 
present alone, the lesions which they produce 
are edematous rather than gaseous. Crepitation 
usually cannot be felt unless CL perfringens 
also is present. Its presence must always be sus- 
pected in wounds contaminated by soil or fecal 
discharges or when edema or crepitation is 
present. Infections with gas gangrene organisms 
are so alarming in the rapidity of their spread 
and their high mortality that often treatment 
must be given before the causative organisms 
can be isolated and classified. The surgical 


treatment ol the x'arious types of gas gangrene 
is the same, and now p()lv\ailcnl sera arc avail- 
able for use until tbc caiisati\'c‘ organism can 
be identilicd. llicn the specific aniiscrum 
should he used. After adccpiatc surgical tneas- 
urcs have been used to reinoM' all in\'()lvcd 
tissues in cases of gas gangrene, ibe wound 
should be treated daily with a creain\' suspen- 
sion ot effective zinc peroxide powder sus- 
pended in distilled water, care being taken to 
effect contact with c\r’rv part of the wound. 
Altbougli all of the gas gangrene' organisms 
are essentially toxin formers, producing true 
exotoxins which arc njpiclly disseminated 
throughout the body, they arc iiwasiw' also and 
spread extensively in tbc tissues. But strangely 
enough, only as death approaches or after 
death is it possible to culti\'atc these organisms 
from the blood. 

Several of the antibiotics are potent 
against most of the gas gangrene organisms 
and if found to be effective by laboratory tests 
should he used both locally and systeniically in 
the treatment of infections caused by the.se or- 
ganisms. 1 lowcver, their use cannot obviate the 
necessity for the surgical removal of all grossly 
infected or injured tissues and foreign bodies 
present in the involved area. 

(E) Closiridimu tetani, This is also a sporc- 
forming gram-positive anaerobe, t)ut it is less 
widely distributed throughout nature than the 
gas gangrene organisms. It is less often found 
in the human intestinal tract than Cl, perfrin- 
gens but is fairly common among persons who 
live in close contact with horses or cattle. I'cr- 
tilized soil is tbc commonest .source, and the 
organisms must be anticipated in wounds con- 
taminated with soil. As is the ca.sc with tiie gas 
gangrene organisms, CL tetani is almost al- 
ways accompanied by other organisms, and the 
associated organisms generally play a part in 
the establishment of the tetanus l)acillus. Lln- 
like the gas gangrene organisms, Cl. ieianl 
does not invade the body; it remains at the 
site of entrance and produces its toxin, which 
has a selective affinity for nerve tissue and 
possibly for muscle also. It has been generally 
accepted for years that the toxin passes up the 
motor nerves to the cord, but Abel and his 
associates Lave cast some doubt on this theory. 
They believe that it attacks muscle directly 
and passes through the lymphatics to the blocxl 
stream and thence to the central nervous sys- 
tem, involving especially the motor cells of 
the cord. The surgical 



55 


Relationship of Bacteriology to Surgery 


largely prophylactic. The debridement of the 
wound, the removal of foreign bodies and the 
scrupulous cleansing of the w^ound, along with 
the administration of antitoxin, are essential. 
If symptoms of tetanus have made their ap- 
pearance, complete extirpation of the focus is 
of utmost importance in order to stop the 
manufacture of the poison and give the anti- 
toxin the best possible chance to neutralize the 
toxin already liberated. Tetanus antitoxin is 
generally indicated as a prophylactic measure 
in all puncture wounds. The use of any anti- 
biotic after tetanus has become established is 
of doubtful value. 

(II) Gram-Negative Anaerobic Bacilli. 

There are a number of anaerobic gram-nega- 
tive bacilli which do not form spores, but 
which are definitely pathogenic. They belong 
to the bacteroides and necrophorus groups. 
They are of some importance in symbiosis 
with other organisms in peritonitis and in 
chronic ulcerations and are associated with, if 
not the cause of, certain forms of chronic ul- 
cerative colitis. The whole group requires fur- 
ther study. 

III. MICROAEROPHILIC ORGANISMS 

The microaerophilic bacteria form a little 
known group of organisms which are inter- 
mediate between the anaerobes and aerobes. 
They grow best in an environment with a di- 
minished oxygen tension, at least when they are 
first isolated from the human body. They may 
perhaps be aerobic organisms which have be- 
come modified by living for a time in the 
intestinal tract or in lymph glands, Such organ- 
isms are frequently missed with ordinary 
methods of cultivation or may grow sparsely 
aerobically. Two types of chronic infections 
have been recognized as clinical entities due 
specifically to these organisms. 

A. Streptococci. Hemolytic Microaerophilic 
Streptococci. These streptococci have been 
found in pure culture in certain chronic ulcera- 
tive nongangrenous lesions which generally 
occur on the abdominal wall, but which may de- 
velop on any part of the body surface. They are 
characterized by an extensive ulceration, with 
undermining of the skin, rolling in of the skin 
margins, and the development of sinuses which 
burrow down between the muscles into the 
neck, axilla, pelvis or groin, or into the vulva 
or scrotum. These infections formerly existed 
for months or even years with gradual progres- 
sion until death ensued as a result either of 


the erosion of blood vessels or of amyloid 
changes in the liver, spleen or kidneys. How- 
ever, in 1935 it was found that in these cases 
there is a favorable response to local treatment 
with zinc peroxide, and the outlook in such 
cases since then has been decidedly fa- 
vorable. 

Nonhemolytic Microaerophilic Streptococci. 
Similar organisms which are not hemolytic but 
which tend to produce methemoglohin on 
blood agar plates have been found in chronic 
gangrenous lesions of the abdominal or chest 
wall following the drainage of peritoneal or 
pleural abscesses. The lesion is extremely pain- 
ful and spreads slowly, with a zone of adher- 
ent gangrenous slough without extensive 
undermining and burrowing or the formation 
of sinuses, such as occur in the condition de- 
scribed above. Outside of the zone of gangrene 
there is a raised, purple, necrobiotic zone, and 
beyond this is a red hyperemic zone in which 
the organism can be found in pure culture. In 
the gangrenous zone it is always associated 
with a staphylococcus. This disease has been 
demonstrated repeatedly to be a synergistic 
infection in which the streptococcus, which 
alone is of low pathogenicity, in some way 
paves the way for the gangrenous action by the 
staphylococcus. Formerly, it was necessary to 
completely excise this lesion to effect a cure, 
but now in most cases either penicillin or 
bacitracin brings it under control without the 
necessity for surgical removal. 

IV. SPIROCHETES 

The Treponema pallidum of syphilis can 
hardly be said to cause surgical infections, al- 
though syphilitic lesions are frequently oper- 
ated on when there has been a mistake in 
diagnosis. On the other hand, some of the 
spirochetes, such as T. macrodentium and T. 
microdentium, and spirilla of the mouth, fre- 
quently find their way into dental abscesses 
which may spread to the cervical lymph glands 
or to the lungs and produce foul-smelling 
abscesses. They frequently occur also in foul 
infections of other parts of the body, especially 
of the hands following human bites. Such 
cases arc helped by the intravenous adminis- 
tration of Neosalvarsan, but, frequently, sur- 
gical drainage or even amputation is required. 
Zinc peroxide is usually effective in eradicating 
these organisms in foul-smelling dental infec- 
tions and humau bites. These organisms are 
particularly susceptible to bacitracin. 



56 Chapter 3. Surgical Bacteriology, 

V. HIGHER MICROORGANISMS 

A. Actinomycetes. Actinomycosis is a dis- 
ease which affects man, cattle and swine and is 
characterized by the development of granulom- 
atous tumors which fistiilizc. hrom tlic 
discharge characteristic yellow sulfur-like gran- 
ules may be obtained. 

B. Biastomycetes. Blastomycosis may he 
either a cutaneous or systemic disease. The 
former is a chronic inflammatory infectious 
skin disease which is characterized by the 
development of papulopustular lesions which 
extend peripherally and form variously sized, 
elevated verrucous patches with sloping borders. 

C. Coccidioides. Coccidioidal granuloma 
is an acute or chronic infection caused by a 
specific fungus. Subcutaneous abscesses, verru- 
cous skin lesions and meningeal, respiratory, 
osseous or other involvement may be observed 
in chronic cases. 

B. Sporotricha. These are rare lesions 
similar in their manifestations to the above. 
Diagnosis is made by cultivation in special 
media or by biopsy. 

POSTOPERATIVE SURGICAL INFECTIONS 

There are certain disturbances of the normal 
physiology which occur during or after an 
operation which favor the establishment of 
infection in other parts of the body. These 
affect chiefly the respiratory, the alimentary or 
the urinary tract. 

A. Respiratory Postoperative Infections, 

During almost all general anesthetics and to a 
less extent with the action of sedatives or nar- 
cotics preliminary to local or spinal anesthesia, 
there is diminution or suppression of the cough 
^refe. Frequently, a paftfcTe" of mucus' oftood 
mr a drop of water enters the larynx and trachea 
in a normal person who has not received any 
medication. It almost invariably starts a violent 
coughing attack, which quickly dislodges the 
particle and frees the trachea from the offend- 
ing substance. On the other hand, it has been 
found that nonirritating substances, such as 
oils, may run down into the larynx without 
starting the coughing reflex. Certain inhala- 
tion anesthetics cause increased salivation and 
increased depth and force of respiration favor- 
ing the entrance of mucus into the trachea and 
bronchi. With almost any anesthetic it may be 
assumed, therefore, that organisms and mucus 
from the mouth and sometimes blood become 
lodged in the respiratory tract below the glottis 


Chemotherapy and Antibiotic Therapy 

—the position being determined b\ the depth of 
the anesthesia, the size of the particle and the 
other factors jircvioiisly mentioiu'd. i urther- 
more, sedatiws, narcotics and anesthetics, as 
well as pain, limit tlie excursion of res[>i ration 
and lessen the aeration of the lungs. Small 
bronchi or bronchioles, partimdarly in die bases 
of the lungs, then become shut oil, and the air 
in the alveoli which lhe\ suppK' heeomes al> 
sorbed. /Xteleetasis results, and if organisms are 
present, the opporUinit\ is gi\'en for them to 
multiply and produce their poisons. 1! they arc 
SLiflieicntly virulent to resist the phagocytic 
action of the lining cells, they may destroy the 
cells and invade the tissues, producing bron- 
chitis, lobular or lobar pneumonia or occasion- 
ally pulmonary abscess.djic pneiimoeoeci which 
are frequently present in the mouth arc the 
organisms most likely to produce these infec- 
tions, especially the pneumonias, hut tlu' other 
organisms also iiiay pla\' a role in the hronehi- 
tidcs and lung al)seesses. The latter lesions 
Frequently reveal the jiresenee of anaerobic or 
microacrophilie streptococci or the ora! spiro- 
chetes and fusiform bacilli. Sometime.s bacteria 
are conveyed to the lungs in pulmonary emboli 
from infected foci. Even if sterile, an embolus 
may procluec an abnormal area in the lung 
which favors the establishment of organisms 
introduced from above. If the embolus is germ- 
laden, infection almost inevitably develops. 

Efforts should be directed to ininimi/.e the 
occurrence of these infections. In certain oper- 
ations the anesthetist may maintain the anes- 
thesia at a level which docs not completely 
obliterate the cough reflex. Lfse of CKJ.j and 
O2 inhalation after operation has been advo- 
cated to increase the anqditudc of res{)iration 
and to free the bronchi from aceumulated 
mucus. Binders which limit the. movement of 
the lower ribs should be avoided, and every 
effort should be made to restore the normal 
physiology as soon as possible. Attempts have 
been made to minimize the bacterial content 
of the mouth and throat before operation by 
the use of various antiseptics, but so far none 
has proved efficacious. Several of the antibiotics 
will materially reduce the number of mouth 
organisms when used in spray or tablet form. 
'When postoperative respiratory infections oe- 
crir, they respond in most instances to appro- 
priate doses of either a sulfonamide or an 
antibiotic. The recently devised “cough ma- 
chine’ is very effective in expelling mucous 
plugs from the bronchi. 



57 


Relationship of Bacteriology to Surgery 


B. Alimentary Postoperative Infections. 
Occasion ally postoperative tonsillitis develops 
following inhalation anesthesia, but only rarely 
after rectal or local anesthesia. Almost always 
the organisms which are active in these cases 
were present in the patient’s throat before 
operation, hut occasionally they are introduced 
if a tube or metal airway is used. These objects 
may traumatize the tonsils, and the churning 
of the pharyngeal mucus may favor the inva- 
sion of the organisms. Postoperative parotitis is 
a distressing complication of frequent occur- 
rence in debilitated persons. It seems to be fa- 
vored by dryness of the mouth. The offending 
organism is almost always the hemolytic Micro- 
coccus pyogenes var. aureus. The organism 
probably reaches the gland by way of the duct, 
although it is surprising that other organisms 
more common in the mouth do not occasionally 
cause parotitis. One can only surmise that the 
parotid gland is particularly susceptible to the 
micrococcus. The esophagus, stomach and duo- 
denum are not often affected by bacterial in- 
vasion after operation. Paralytic or mechanical 
ileus, however, may have a bacterial element. 
The stasis of intestinal contents inevitably 
causes retention of irritating substances, both 
chemical and bacterial, in contact with the 
mucous membrane, which is stretched by the 
accumulation of gas and compromised by a 
diminished blood supply. The amount of ab- 
sorption from intestinal distention has been a 
matter for debate and experimentation. The 
facts are little known, but the possibility of a 
large bacterial factor in the production of 
clinical symptoms cannot be denied. The fre- 
quency of rectal irritation from the mechanical 
apparatus used to overcome postoperative dis- 
tention occasionally favors invasion of the 
perirectal tissues by intestinal bacteria, with 
subsequent abscess formation. This possibility 
should always be borne in mind, and rectal 
treatments should not be continued longer or 
carried out oftener than is absolutely necessary. 

C. Urinary Postoperative Complications. 
Frequently after an operation in the lower 
abdomen or on the pelvic floor or perineum, 
the reflex spasm of the sphincter of the bladder 
prevents evacuation and results in retention of 
urine and distention of the bladder. This may 
become so painful that it must be relieved by 
catheterization. It is difiicult, if not impossible, 
to sterilize the meatus of the urethra, and con- 
sequently any instrument is certain to carry 
organisms into the upper urethra or the blad- 
der. If distention occurs again or if the bladder 


fails to empty completely, the organisms may 
be retained; they may grow in the urine and 
invade the bladder wall. They may invade the 
ureters also, either by entering the meatus and 
infecting the urinary column or by passing up 
in the wall. Thus pyelitis or pyelonephritis 
may develop. Infection occurs in a large per- 
centage of patients who require catheterization. 
The organisms most often found are the Esch. 
coli and intestinal green streptococci, both of 
wTich apparently grow' readily in urine. Ob- 
viously, catheterization is to be avoided if pos- 
sible and always performed with the utmost 
care in order to minimize the introduction of 
organisms. It is also important to prevent the 
collection of residual urine and to remove 
speedily the contaminating organisms before 
they can gain a foothold. When they are once 
established, it is difficult to eradicate them, but 
this may be done by assiduously flushing the 
bladder with alkaline diuretics, alternating 
with acidifying antiseptics, or, if that fails, by 
the use of an appropriate and potent bacterio- 
phage. Sulfadiazine in doses of 0.5 gm. every 
six hours has been found to be effective against 
most strains. When given by mouth it is 
eliminated through the kidneys, if they are not 
diseased, in sufficient concentration to inhibit 
the growth of the organisms materially. 

Antibiotics potent against the causative or- 
ganisms are usually effective in clearing up 
urinary tract infections if there is no obstruc- 
tion to the urinary flow, because these antibac- 
terial agents are often concentrated in the 
urine during their excretion from the body, 

ENTRANCE OF BACTERIA INTO THE BODY 

The human body is covered by a layer of 
hornified epithelium of varying thickness 
which is punctured by the ducts of the sweat 
and sebaceous glands and by the hair follicles. 
At the orifices of the body, the skin joins with 
mucous membrane, which lines the inner sur- 
faces of the alimentary, respiratory and geni- 
tourinary tracts and the conjunctival surface 
of the eyes. On the surface of the mucous 
membrane, the ducts of various glands pour out 
secretions: saliva, mucus, bile, gastric and pan- 
creatic juice, urine and various minor glandular 
secretions of the respiratory and alimentary 
tracts. Bacteria cannot penetrate the horny 
layer of the skin, but certain species, such as 
the staphylococci, are able to live in the ducts 
and may at times grow there and produce 
poisons. Such toxic products may then have 



58 Chapter 3. Surgical Bacteriology, 

the power to destroy the thin layer of epithc- 
lium lining the ducts and permit the organisms 
to enter the subcpithclial layers. Organisms 
which cannot grow, metabolize and produce 
lytic substances on or in the skin must await 
some mechanical force to transplant them into 
the deeper layers. On the surface of the mu- 
cous membranes, particularly of the alimentary 
tract, are substances which can he utilized by 
a large number of bacterial species for food 
which will permit them to grow and metab- 
olize and give off poisons or waste products 
which may injure the surface epithelium. At 
the same time the inner surfaces of the body 
are subject to minor injuries wdiich carry the 
.surface organisms into the deeper tissues. It 
may be said in general that bacteria usually 
enter into the subcutaneous tissues through 
breaks in the continuity of the skin rather than 
through an erosion of the surface by bacterial 
products, and bacteria enter the submucous 
tissues through the erosion of the surface by 
bacterial products rather than through wounds. 
Furthermore, there are certain physiologic 
changes in the surface of mucous membranes 
which may render them liable to the invasion 
of bacteria. For example, the congestion that 
occurs in the nasal mucous membrane in re- 
sponse to mechanical, chemical or thermal stim- 
uli renders it more permeable than when it is 
not congested. Similarly, in the genital tract the 
lining of the uterus after menstruation or 
parturition is more liable to penetration by 
organisms than it is normally. The congestion 
of the mucous membrane of the urethra during 
intercourse probably renders it more permeable 
to gonococci than it would be when at rest. In 
the alimentary tract there is always a certain 
amount of indigestible material which may 
traumatize or puncture the mucous membrane 
and permit organisms to enter. It is generally 
believed, however, that typhoid, cholera and 
dysentery organisms, as well as the tubercle 
bacillus, may pass through an intact intestinal 
wall Any obstruction to the onward flow of the 
intestinal contents increases the possibilities of 
mechanical and chemical injury, because of the 
greater time of contact of the irritating sub- 
stance and because of the pressure exerted on 
the intestinal wall by the accumulated fecal 
fluid and gases. This may result in the cutting 
off of the blood supply so that the surface cells 
may die, disintegrate or he torn apart. 

The basal layers of the epidermis consist of 
■ totind or polygonal cells which have normal 


Chemotherapy and Antibiotic Therapy 

nuclei and are connected to neighboring cells 
by cellular bridges. No Idnod \ essels enter tlie 
epidermis, but there is a eireulation of lympli 
beneath the bridges which nourishes the cdls 
for the first few layers, i liglicr up, the cclk 
become smaller and (latter, tbe\ begin to lose 
their nuclei and they heeome packed closely 
together. Still higher they lose their nuclei and 
become completely kcralini/ed. Any cut or 
abrasion which penetrates to the layer around 
which fluid is circulating may carry organisms 
into these intercellular s}xices. d’hey may then 
be carried off in the current directly or may 
lodge in these spaces, coloni/c and produce 
poison which erodes c'apillaries or Kinphatics 
and pave the way for deeper penetration by the 
organisms. 

SPREAD OF BACTERIA WITHIN IHF BODY 

When bacteria pass the first harrier, cither 
because they have i)roducccl an t'rosioii or 
because they have been carried in through a 
wound, they reach the subepithclial tissues. II: 
purulent discharges have Itceh ' mtroducccl 
directly from another human source, the dose 
of organisms may be large and aceompimied by 
toxic products, which may injure the tissue 
cells at once, LIsually, however, the dose is 
small, and the organisms hax’c come from an 
entirely different environment. If they arc to 
produce an infection, the orgapisms nuisi main” 
tain themselves in the lace ol' hostile forces, 
namely, the tissue, fluids, tlie bbrod and the 
phagocytic cells. As a rule, the bacteria arc 
promptly destroyed; but if a few survive, 
they presently begin to niultifdy. Finally, a 
colony of organisms is produced, and the waste 
or toxic products accumulate. If these products 
are fluid, they may diffuse outward in all direc- 
tions. The fluid may attract or repel leukocytes 
and according to its concentration may be de- 
structive to the neighboring tissues and cause 
liquefaction, thus producing a little fluid space 
around the colony. Organisms may then be 
carried away from the surface of the colony by 
the currents of fluid circulating ahcait the col- 
ony. These organisms will he stopped for a 
while, however, by some intercellular fibrils or 
by the endothelial lining of capillaries or lym- 
phatics. As the lymphatic system is closed, they 
cannot enter the lymphatics directly, They 
may, however, be picked up by the wandering 
cells of the blood or by the endothelial phago- 
cytes and may be destroyed or carried into tltc 
capillaries or lymphatics. If nbfwnrvfntit' 



Chemotherapy and Antibiotic 

not lake place, the organisms may multiply and 
produce a new colony at a distance from the 
parent colony, the whole process perhaps being 
repeated there. The bacterial products, besides 
liquefying tissue, frequently cause thrombosis 
of capillaries, and then there may be subse- 
quent invasion of the clot by the liquefaction of 
the lymphatic or capillary wall. As the clot 
increases in size within the vessel, the bacterial 
invasion follows until the next larger vessel is 
reached. Then this radicle may become throm- 
bosed, or pieces of the infected clot may he 

CHEMOTHERAPY AND 
OF SURGICAL 

Chemicals and other medicaments have been 
used since prehistoric times for the prevention 
and treatment of infection in traumatic and 
accidental wounds. These ranged from various 
extracts of herbs and various forms of alcoholic 
beverages in the early days to the knowm chem- 
ical compounds of more recent times. During 
World War I many studies were made of the 
antibacterial action of dyes and mercurials, fol- 
lowing Ehrlich’s lead. However, they were dis- 
couraging, because these chemicals were often 
inactivated by tissue fluids and were often 
found to be more damaging to the leukocytes 
and tissue cells than they were to the contami- 
nating bacteria. 

Zinc Peroxide. The use of zinc peroxide 
as a wound antiseptic was suggested by Elias in 
1903 and favorable results were reported in the 
treatment of several skin diseases and of acute 
and chronic leg ulcers. Laurent was the first to 
demonstrate that zinc peroxide delivered oxy- 
gen slowly over a period of time. He found 
that it was not only bacteriostatic, but that it 
also detoxified the poisonous products of cer- 
tain bacteria. He did not study its action on 
microaerophilic organisms or strict anaerobes. 
Laurent s reports were not given much cre- 
dence, however, possibly because zinc peroxide 
treatment was not consistently satisfactory. 

Interest in this agent from a therapeutic 
standpoint gradually waned until the early 
1930’s, when it was again taken up and tried 
out for its possible benefit in the treatment of 
chronic undermining burrowing ulcers caused 
by a microaerophilic hemolytic streptococcus. 


Therapy of Surgical Infections 59 

thrown off into the lymph or blood stream and 
carried to the next narrow portion of the capil- 
lary bed, either in the lungs or the liver. If 
there are individual organisms or bits of blood 
clot which are smaller than the capillaries, they 
may pass through the lungs to the pulmonary 
veins and then, coursing through the heart, 
may be thrown off into the arterial side and 
caught in the peripheral capillary network or 
destroyed in the blood. If caught, they may 
again start a metastatic colony, with a repeti- 
tion of this process until death ensues. 


ANTIBIOTIC THERAPY 
INFECTIONS 

The prompt clinical response of this rare but 
distressing and often fatal disease was striking 
in some cases. However, there were certain 
technical difficulties in obtaining consistently 
effective material, which probably also explains 
the earlier variable results of treatment. When 
these problems had been solved, zinc peroxide 
proved to be not only bacteriostatic for many 
of the aerobic pyogenic organisms, including 
the staphylococcus, streptococcus and coliform 
groups, but also bactericidal for the strict ana- 
erobes and microaerophilic organisms. Further- 
more, it was found to neutralize the toxins of 
both Clostridhim tetani and Clostridium yer- 
fringens. It is not injurious to leukocytes and 
favors their phagocytic action. It seems to have 
a chemotactic action for leukocytes, calling 
forth exudate from the wound surfaces and 
stimulating the growth of granulation tissue 
and epithelium. 

Zinc peroxide soon became widely used in 
the treatment of various forms of ulcerations 
and of infections along the alimentary tract 
where direct application could he made. This 
was passible for infections of the mouth and 
throat and for foul-smelling abscesses of the 
neck generally due to the anaerobic strepto- 
cocci and the spirochetes of the mouth. Where 
local application could be made, favorable re- 
sults were obtained with proctitis, anorectal 
infections and ulcerative colitis. Human bites, 
putrid lung abscesses and mediastinal infec- 
tions responded to its use, and after excision of 
all of the involved muscle tissue, it gave favor- 
able results when applied to infections like 



60 Chapter 3, Surgical Bacteriology, 

gas gangrene, where it had the opportunity of 
not only killing the clostridia on contact but 
of detoxifying any elaborated toxins locally. 

The great drawback to the use of zinc per- 
oxide is that it cannot be given systcmically for 
invasive infections. Direct contact has to be 
maintained with the whole wound surlace, and 
the zinc peroxide has to be kept wet during 
that period of contact in order that it may pro- 
duce a continuously oxygenated environment. 
Many of the functions of zinc peroxide ha\'e 
now been taken over by the antibiotics, but it 
has a role to play in certain surgical infections 
where it is still the antibacterial agent of 
choice. 

Siilfonamides. The introduction of the sul- 
fonamide drugs in 1935 and the subsequent 
demonstration of their effectiveness in hemo- 
lytic streptococcic infections swept aside the 
attitude of nihilism which had prevailed in 
the field of bacterial chemotherapy since Ehr- 
lich’s time. The evidence that the course of a 
bacterial infection could be interrupted or 
modified by systemically administered drugs 
stimulated the development of a whole scries of 
compounds, including sulfanilamide, sulfadia- 
zine, penicillin, streptomycin, bacitracin and 
many other synthetic chemicals and antibiotics. 
The addition of each one of these new sub- 
stances further advanced the scope of effective 
chemotherapy, so that what was originally an 
effective form of treatment against only hemo- 
lytic streptococcic infections became broadened 
to include meningococcal, pneumococcal and 
staphylococcal infections and finally almost all 
of the acute suppurative and even some of the 
chronic granulomatous diseases, such as tuber- 
culosis. The impact of the evolution of chemo- 
therapy on surgical infections has been so 
great as to bring within reach the elimination 
of infection as a cause of death in surgery, a 
goal the attainment of which would in 1935 
have seemed entirely beyond the bounds of 
possibility. What were formerly considered to 
be 'Tasic principles'' of therapy in surgical in- 
fections have undergone drastic revision during 
the chemotherapeutic era, and still further 
modifications are to he expected during the 
coming years. Chemotherapy has contributed 
greatly to the progress of physiologic surgery 
through removal from the surgeon's mind of 
fear of infection as a decisive factor in the 
choice and timing of operative procedures. 
Sulfanilamide. The first sulfonamide com- 
pound was a red azo dye, sulfamidochrysbidin, 


Chemotherapy and Antibiotic Therapj 

which was synthesized in the laboratory uftfi 
1. G, Farbcn Gompan) in Ciernian} and first 
described as a therapc'utie agent 1)\ Domagl, 
in 1935. This compound was a union of Uvii 
principal components: soil anilamidra an ani- 
line derivative which had been list'd for many 
years in the dye indust r\ as a means of ii> 
creasing the fastness of dyes ior wool protein, 
and chrysoidin, one of a group ol dyes whidi 
had for years been siisjxx'ted of jxissessing 
chemotherapeutic activity. I he eoinpound was 
patented under the trade name "Prontosild 
and in preliminary clinical trials both in Ger- 
many and in England it was {oiintl to pos.sess 
curative clfccts in acute hemohlie strt'iVocoedc 
inl'eetions. However, it was not long before it 
was discovered that the antihaeteiial elleet o[ 
Prontosil was due enliredy to the stillanilamitlc 
which was liberated in llu' both following its 
administration. Unlike Prontosil, sulfanilamide 
was active against hemolytic strt'ploeoeei in 
the test tube; union with the eke radical was 
.shown not only to eonlrihiile nothing to the 
chemotherapeutic cfiecl but aetiialK to tend to 
limit its magnitude, h'urthennore, siillanila- 
mide could not he patented and there! ore be- 
came available all enur the world as a 
remarkably inexpensive drug with great po- 
tentialities. 

The first significant demonstration of the 
value of sulfanilamide in a surgical inlection 
was made by Leonard Colehrook, working in 
the septic unit of the Queen Gharlotte’s Ma- 
ternity Hospital in London. Golchrook was 
responsible for several observations which re- 
main generally significant to this clay- 1 Ic 
showed that after treatment with sulfanilamide 
the blood of the patient became rapiclK' en- 
dowed with the capacity to kill many times 
the number of hemolytic streptococci that 
could he killed by the blood of a normal sub- 
ject or the blood of an infected patient prior 
to receiving the drug. This served to exj)lain 
in a general way why the sulfonamides were 
effective as chemotlwrapeutic agents. Second, 
he okservecl that the bacteria were not all 
destroyed in the body by the action of the drug, 
and he correctly inferred that the major role 
of the sulfonamides was to interfere with the 
ability of hemolytic streptococci to multiply in 
the body, but that the actual clearing of bac- 
teria from the infected area occurred through 
the continued operation of the immunity mech- 
anisms of the patient. lie pointed out that 

sulfanilamirl^^ - 



Chemotherapy and Antibiotic Therapy of Surgical Infections 63 


dealing with the true in\^asive factor in hemo- 
Jytic streptococcic infections, naraeh’, the multi- 
plication of streptococci in blood and in tissues 
of fairly normal architecture. It was later ob- 
served by American workers that the use of 
sulfonamides in the body was limited in pro- 
portion to the amount of breakdown of tissue 
which occurred at the site of the infection 
and that necrosis and suppuration in the in- 
fected area resulted in liberation of substances 
which were specifically antagonistic to sul- 
fanilamide, both in the body and in the test 
tube, as well. 

These fundamental principles, developed by 
Colebrook and others, have continued to ap- 
ply to the held of sulfonamide therapy, even 
in the face of the development of man\' new 
drugs enjoying a range of activity far greater 
than that of sulfanilamide itself. 1942, both 
sulfathiazole and sulfadiazine had been dis- 
covered and had been found to be effective not 
only against most streptococcic infections but 
against pneumococcic, meningococcic and gon- 
ococcic infections as well; with the use of these 
drugs it appeared that mortality rates from 
peritonitis and from infection in accidental 
wounds would be significantly reduced, and 
the pessimistic attitude which had existed 
prior to 1935 had been replaced by a sense of 
confidence that still newer drugs would be 
found which would have curative action in all 
types of bacterial infections. 

Uie sulfonamides are limited in their use- 
fulness in surgical infections in several im- 
portant ways. In the first place, most of the 
so-called surgical infections are characterized 
at some stage in their development by the 
presence of a suppurating focus of infection in 
soft tissue or bone. If the sulfonamide is ad- 
ministered at a sufficiently early stage in the 
development of the infection, namely, before 
tissue breakdown has occurred through action 
of bacterial enzymes and interference with 
blood supply, the further progress of the lesion 
may be checked; however, once breakdown of 
tissue has occurred, the drugs are incapable of 
effecting the further destruction of bacteria in 
the focus, and it becomes necessary to resort 
to surgical methods of eradicating the lesion. 
The next important limiting factor of sulfona- 
mides in the treatment of surgical infections 
derives from the comparatively low degree of 
activity of sulfathiazole and sulfadiazine on 
the Micrococais fyoge?ies var. aureus. The 
overwhelming majority of the infections which 


are called “surgical ’ are due to this particular 
organism, including boils, carbuncles, acute 
and chronic osteomyelitis and most infections 
in operative and accidental wounds. Although 
the administration of these drugs undoubtedly 
aided in effecting the localization of these in- 
fections and probably reduced fatality rates as 
a result, the fact remains that the usefulness of 
sulionamicles in these lesions fell tar short of 
what could be hoped for from an ideal chemo- 
therapeutic agent; consequently, the develop- 
ment and use of penicillin is of great signifi- 
cance in the field of surgical infections. 

Sulfadiazine. Sulfadiazine appears to com- 
bine in fuller measure than any other member 
of this series the properties of minimal toxicity 
and maximal effectiveness in a wide variety of 
infectious diseases. It has, therefore, to a large 
extent replaced most of its predecessor drugs 
in sulfonamide therapy. The great successes 
of penicillin in most of the infections formerly 
treated by the sulfonamides have relegated 
even sulfadiazine to a position of relatively 
minor importance in the therapy of surgical 
infections. Where penicillin is not available, 
sulfadiazine can be used with excellent results 
in the treatment of most hemolytic streptococcic 
infections, and in pneumococcic infections the 
results with penicillin are by no means mark- 
edly superior to those which can be obtained 
with sulfadiazine. However, sulfadiazine does 
possess a significant measure of toxicity, par- 
ticularly because of the possibility that it may 
produce obstruction within the upper and lower 
urinary tract by formation of precipitated crys- 
talline concretions and because certain indi- 
viduals may become sensitized to any one of 
the sulfonamides by prolonged administration. 

Sulfadiazine is now most frequently em- 
ployed in surgical practice in combination with 
penicillin and streptomycin in the treatment 
of mixed bacterial infections, such as peritonitis, 
in which it is desired to make recourse simul- 
taneously to several weapons in attacking a 
resistant type of infection. ^Ifadiazine re- 
mains a useful drug in the treatment of uri- 
nary tract infections due to gram-positive cocci 
and to Escherichia colh and in resistant cases 
it may be turned to as an alternative to other 
drugs which have been found to be ineffective. 
It is obvious, however, that these limited indi- 
cations leave only a relatively small place fox 
sulfonamide treatment in contemporary sur- 
gery. When sulfadiazine is employed, it is 
given in doses of 4 to 8 gm. a day, either by 



62 Chapter 3. Surgical Bacteriology, 

mouth or intravenously in the form of the 
soluble sodium salt. The concomitant admin- 
istration of an alkali, such as sodium bicar- 
bonate by mouth or h; molar lactate solution 
intravenously, will reduce the toxic potentiality 
by minimizing the likelihood of precipitation 
of sulfadiazine in the urinary tract. 

PenidSliti. Penicillin came closer than the 
sulfonamides or any of the other antibacterial 
agents to meeting the criteria of the ideal chemo- 
therapeutic agent and rapidly achieved a preemi- 
nent position in the therapy of surgical inlcc- 
tions. First reported by Alexander Fleming in 
1929, as a product of the mold Penicillhim nota- 
tmUj it was isolated and developed as a practical 
chemotherapeutic agent by f ioward Florey and 
his colleagues at Oxford University in a series 
of studies which commenced in 1940. Un- 
doubtedly the success which had attended the 
introduction of the sulfonamide compounds 
played an imporant part in inspiring the trans- 
lation of penicillin from a laboratory curiosity 
to a practical therapeutic agent. Florey and his 
associates had commenced early in World 
War II to find a drug which would be effective 
in the treatment of infections due to the 
Micrococcus 'pyogenes var. aureus, since it was 
recognized that this organism was of major im- 
portance in wound infections incident to war- 
fare. In fact, it was the failure of the sulfona- 
mides to measure up to the requirements in 
staphylococcal infections that led to further 
studies with penicillin. As a result of the mili- 
tary urgency behind this search and the con- 
centrated direction of British and American 
production facilities, it was possible within four 
years to push the producton to a point where 
penicillin was available for treatment of the 
large number of casualties occurring between 
the Normandy invasion and the final termina- 
tion of hostilities. Wartime experience with 
penicillin acquired both in military hospitals 
and in civilian institutions established the im- 
portance of the drug in surgical practice with 
an impetus which was carried on into the post- 
war period. It is doubtful whether any substance 
as difficult to produce as was penicillin, in the 
early days of its development, could have 
reached its present place in such a short time 
without the pressure of war. ' 

Penicillin is the active principle secreted hy 
certain strains of Penicillhim notattim during 
growth in suitable media. There are, in fac^ 
several chemical variations of penicillin des- 
ignated as F, G, X and K, all of them complex 


Chemotherapy and Antihiotic Therap'j 

organic acids difl'criag (m!y in their major side, 
chains. The type of penicillin which is naosi 
readily produced in a s ale ol cr\siallinc 
is penicillin G, and most ol the crystalling 
preparations now available arc either th 
calcium or sodium salts oi this substance. Th 
relative therapeutic e(lccti\ cncss ol the diilcrcni 
penicillins has not been liillv evaluated, but it 
seems probable that penicillin X may undei 
certain conditions possess therapeutic' properties 
superior to those of penicillin G. 

Pharnnicology. Penicillin is most eommonlv 
administered in the form of ac[ueoiis soliitiom 
injected intramuscularly. Because of previous 
experience with the sulfonamides, which had 
been found to he most .efleetivv when given at 
Frequent inlcivals so as to maintain lairly uni- 
Form blood Icveds throughout the twenty four 
hour perioclj it has beeii eustoinarv' to give 
penicillin at intervals of every three or four 
hours. Early experience with pcmieillin cleni- 
onstratccl that doses as low as SOOO units every 
three hours were sulheient to bring scrioui; 
septicemias due to the hemolytic Micrococm 
pyogenes var. aureus under control, l„ater when 
penicillin was in greater supply and thcrcForc 
more readily available, larger doses were em- 
ployed with a wider margin of therapeutic 
coverage. Furthermore, its apparent lack of 
toxicity rendered excessiv'c dosage relatively 
safe. Later exjoericncc revealed tlrat in certain 
types of bacterial inlcctions, particularly pneu* 
mococcic pneumonia, excellent therafwutife* re- 
sults could be obtained by the injection of 
approximately 300,000 units iiuranniscularly 
every twelve hours, but in the more severe 
types of invasive infections, it is probably pref- 
erable to adhere to the former short-interval 
schedule. Penicillin injected intramuscularly 
becomes rapidly distributed tliroughoul the 
body fluids and will even penetrate inllamma- 
tory membranes, provided some vascularization 
exists. Flowever, only meager concentrations are 
developed in the cerebrospinal fluid and in 
purulent fluids enclosed in well- localized ab- 
scess cavities, including empyema pockets and 
infected joints. Therefore, maximal utilization 
of penicillin can be obtained in such cases 
only by combining topical injections with sys- 
temic administration. Penicillin directly intro- 
duced into such cavities tends to remain 
present in high concentration for many hours 
because of delay in its removal by blood and 
lymph, and it therefore attacks the infecting 
bacteria with the greatest possible effectiveness. 



Chemotherapy arid Antibiotic Therapy of Surgical Infections 


Unlike the sulfonamides, penicillin is not in- 
hibited by the products of tissue breakdown 
in -pus and necrotic tissue, and the antibac- 
terial action of penicillin in such areas requires 
only that it be brought into contact with bac- 
teria in concentrations above the minimal in- 
hibitory level for that particular strain of 
organism. 

One exception to this rule appears in in- 
fected areas containing bacteria capable of 
producing a penicillin-destroying enzyme, peni- 
cillinase. Escherichia coli and other gram-nega- 
tive aerobic bacilli are conspicuous in this 
regard, so that the usefulness of penicillin may 
be impaired in the treatment of mixed infec- 
tions where a penicillinase-producing organism 
is present. Furthernore, many organisms, par- 
ticularly staphylococci, tend to develop resist- 
ance to peniedlin when permitted to multiply 
in concentrations of the drug too low to bring 
about their early destruction. This process is 
apparently a result of the selective survival of 
more highly resistant variants, which are prob- 
ably present to some extent in all bacterial 
cultures, and is not a consequence of acquisi- 
tion of resistance by any individual organism. 
In practice it is therefore desirable consistently 
to check the sensitivity to penicillin of the or- 
ganism in question and to change to other 
chemotherapeutic agents when highly resistant 
variants appear. 

The most remarkable characteristic of peni- 
cillin as a chemotherapeutic agent is its ex- 
tremely favorable toxicity index. It is able to 
produce effects on bacteria in the body which 
are actually bactericidal without causing any 
demonstrable effects on the metabolism of the 
host cells. The only exceptions to this are the 
allergic sensitivity reactions which have been 
reported with rapidly increasing frequency as 
penicillin has been used more and more indis- 
criminately. It is advisable to inquire if the 
patient has any knowledge of allergic tenden- 
cies before the administration of penicillin. 

Dosage. With decreasing cost and increas- 
ing availability of the drug, there has been a 
progressive tendency to increase the customary 
dosage, with the result that undoubtedly much 
penicillin is wasted. Approximately ten to 
twenty times as much penicillin is now being 
given for the treatment of acute staphylococcus 
infections as was given during the war years of 
scarcity, and yet the therapeutic results are 
not strikingly superior with the larger dosages. 
However, there is a natural tendency to wish 


63 

to be on the “safe side," and, recognizing the 
existence of the occasional resistant case in 
which good results can be obtained only with 
larger doses, it is not unreasonable to employ 
the latter habitually. In types of infections 
known to be general!}^ susceptible to penicillin 
therapy, it is appropriate to gi^^e approximately 

25.000 to 50,000 units every three hours, or 

300.000 units e\’cry twelve hours, if it is de- 
sired to avoid the burden on nurses and pa- 
tients of the short-in ter\^al dose schedule. 
However, in more resistant types of infections, 
such as peritonitis or gas gangrene, it u'ill oc- 
casionally be desirable to increase the dosage 
to as much as 2 to 10 million units per day. 
There is sound experimental evidence that ade- 
quate responses to penicillin therapy in the 
latter conditions will often depend upon the 
resort to doses of this magnitude. Penicillin is 
frequently given by mouth hut the amount 
absorbed from the alimentary tract is variable 
and sensitivity reactions are frequent. 

When penicillin is employed topically in the 
treatment of soft tissue infection, empyema, 
meningitis, suppurative arthritis, etc., it may 
be used in concentrations of 1000 to 10,000 
units per cubic centimeter without locally in- 
jurious effects, although it seems probable that 
the lower concentrations are as effective as the 
higher. Further mention will be made of this 
subject in conjunction with specific conditions 
in which local therapy is desirable. 

Streptomycin, The most important short- 
coming of penicillin in relation to infections 
in the surgical field is its lack of conspicuous 
effect against the gram-negative bacilli, espe- 
cially Escherichia colh Pseudomonas aeruginosa 
and Proteus vulgaris, and its apparent lack of 
any action on Mycohacteriwn tuberculosis. 
Therefore, the discovery and development of 
streptomycin was of considerable interest to 
surgeons. Streptomycin, which is derived from 
Actinomyces griseus, was originally discovered 
by Waksman and his associates of Rutgers 
University, in 1942. Although displaying sig- 
nificant activity against gram-positive organ- 
isms which are especially sensitive to penicillin, 
it is also quite active against many types of 
gram-negatve bacilli and against MycobacterE 
um tuberculosis. In its general pharmacologic 
properties it is somewhat similar to penicillin, 
being rapidly distributed through the body 
fluids following intramuscular injections and 
then rapidly excreted by the kidneys, although 
somewhat less rapidly than is penicillin. 



64 Chapter 3, Surgical Bacteriology, 

Although the number of infections en- 
countered in surgery which require a drug 
with streptomycin's range of effectiveness is 
relatively small in proportion to the number 
for which penicillin is indicated, the position 
of streptomycin as an important therapeutic 
weapon is now^ firmly established. It is espe- 
cially useful in the treatment of bacteremias 
in which a gram-negative bacillus is the pre- 
dominant organism, and it is possibly of value, 
administered in conjunction with penicillin, 
in the ti eatment of bacterial infections, such as 
peritonitis of intestinal origin. Of particular 
interest is the fact that streptomycin is a useful 
repressive drug in the treatment of tuberculosis 
and in this connection is a valuable agent to 
use in conjunction with surgical eradication of 
those types of tuberculous infection which 
come within the scope of the surgeon. 

The factor of toxicity is of greater impor- 
tance with streptomycin than it is with peni- 
cillin, particularly because of a tendency of 
streptomycin to cause damage to the vestibular 
portion of the eighth cranial nerve. This is a 
peculiarly selective effect which has not yet 
been explained, but it is known that the likeli- 
hood if its occurrence is closely related to 
time-dose factors. Doses of 1 gm. per day can 
apparently be given for long periods without 
producing eighth nerve injury. However, as 
the dose is increased to 2 or 4 gm., the likeli- 
hood of the appearance of the toxic effect is 
increased, and the time required for its ap- 
pearance is progressively diminished. The ves- 
tibular injury produced by streptomycin is no 
contraindication to the administration of this 
drug in situations where no other means is 
available for combating the infection, but it is 
of sufficient importance to discourage the sur- 
geon from using streptomycin without a clear- 
cut indication. 

Another important characteristic of strepto- 
mycin is the tendency of most organisms 
which are primarily sensitive to it to become 
rapidly resistant as therapy is continued. 
Within as short a period as forty-eight hours, 
a bacterial population which is predominantly 
sensitive can be transformed into one pre- 
dominantly so resistant as to preclude any possi- 
bility of obtaining any significant therapeutic 
effect. In the case of Escherichia coli infec- 
tions, the development of resistance is likely 
to take place with this order of rapidity. How^* 
ever, in tuberculous infections the development 
of resistance takes place much more gradually, 


Chemotherapy and Antibiotic Therapy 

and treatment can continue eircctlvdy over 
periods of many weeks. 

The results obtained from the topical use of 
streptomycin have not been as striking as those 
obtained with the topical use of penicillin. 'I’his 
may be due to fundamental dillcrcnces in the 
nature of the action of these two drugs, but 
is probably due in large part to the laet that 
localized infections cojUaining organisms pe- 
culiarly sensitive to streptomycin are likely to 
occur only in tissues deprived of their normal 
blood supply by scarring and necrosis. In such 
cases it is better to attcmj)t by surgical means to 
correct the local physioksgic disorder rather 
than to attempt to rely solely upon antilxicterial 
measures in eradicatijig what is largely a sapro- 
phytic infection. 

Baciiracin. The next antibiotic to achieve 
a place of usefulness in surgical practice was 
bacitracin. This antibacterial agent was dis- 
covered in 1943 by Miss Balbina Johnson in 
the Laboratory for Bacteriological Research of 
the Department of Surgery of Columbia LI Di- 
versity under my direction during the 
course of a search for bacterial antagonists 
among organisms found in cultures of de- 
brided tissue from accidental wounds. '’Hw 
parent organism producing bacitracin is a 
gram-positive aerobic spore-forming bacillus 
of the Bacillus subtilis family. The antibiotic 
has been shown to be particularly useful in 
the treatment of infections due to gram- posi- 
tive organisms with either natural or acquired 
resistance to penicillin, including Micrococciis 
pyogenes var. aureus, hemolytic and nonhemo- 
lytic streptococci and clostridia. Bacitracin first 
demonstrated its usefulness when it was ap- 
plied locally to surgical infections such as fu- 
runcles, carbuncles, superficial abscesses and 
infected wounds and burns. It was shown to 
have an antibacterial spectrum very similar 
to penicillin. It is not inhibited by pus, blood 
or broken down tissue. Furthermore, it is not 
inactivated by the penicillinase producers. Al- 
lergic manifestations are almost never en- 
countered. 

Unlike penicillin but similar to streptomycin, 
bacitracin is not absorbed to any degree from 
the gastrointestinal tract. For systemic admin- 
istration, therefore, it has to be given intra- 
muscularly or intravenously. The early 
experiences with the systemic (intramuscular) 
administration of the first bacitracin manu- 
factured by the '‘surface growth method” dem- 
onstrated its effectiveness in the treatment cjI 



Chemotherapy and Antibiotic Therapy of Surgical Infections 65 


systemic infections clue to susceptible organisms 
in doses of 5000 to 20,000 units cver\' eight 
hours. Dosage intervals could be prolonged be- 
cause of its slower excretion w'hen compared 
with penicillin. Transient albuminuria was 
usually observed, but this was considered 
inconsequential in doses up to 200,000 units 
a day. However, when a much more eco- 
nomical method of manufacture in deep tanks 
was devised, the bacitracin so produced was 
found to contain more of this nephrotoxic 
element, and different lots were found to vary 
considerably in their content of this factor. For 
this reason, the systemic administration of baci- 
tracin was curtailed for a period until further 
methods of purification were found and the 
upper limit of dosage safety could be deter- 
mined. Finally, a preparation was produced by 
three different manufacturers of sufficiently low 
toxicity to be acceptable to the Food and Drug 
Administration and the Council on Pharmacy 
and Chemistry of the American Medical Asso- 
ciation for systemic administration in doses up 
to 100,000 units a day, provision being made 
for an adequate intake and output of fluids. 

The So-Called Broad Spectrum Antibiotics. 
The search continued for new antibiotics 
which would fill in the gaps left by penicillin, 
streptomycin and bacitracin. This research was 
carried out for the most part by pharmaceuti- 
cal houses with large funds at their disposal. 
Many active agents were found to be produced 
by organisms commonly present in the soil, but 
they were too toxic for clinical use. However, 
diligent search finally yielded one after the 
other, Chloromycetin reported by Dr. Paul 
Burkholder in 1947, Aureomycin by Dr. Benja- 
min Duggar in 1948, and Terramycin by a 
group under the direction of John L. Smith in 
1950. These came to be known as the broad spec- 
trum antibiotics, because certain viruses and 
rickettsiac as well as most of the gram-negative 
and gram-posi'ive bacteria (excepting the myco- 
bacterium of tuberculosis) were susceptible to 
them. 

One great advantage of these three anti- 
biotics is that they are absorbed from the 
alimentary tract and therefore can be given by 
mouth. One disadvantage is that in controlling 
certain of the intestinal organisms they permit 
the prodigious growth of others in the alimen- 
tary canal, often causing prolonged and dis- 
tressing and sometimes fatal enteritis. Further- 
more, they are bacteriostatic rather than bac- 
tericidal, and while they hold bacteria in check, 


they depend on the humoral and cellular de- 
fenses of the body to destroy the organisms. 

As soon as these three new agents w^ere dis- 
cu\'ercd and their relativ'e safety was deter- 
mined, the respectixu manufacturers sought to 
have them given a clinical trial. 

Chlortetracydine QAiireomychi}. Cliloitet- 
racyclinc was studied extensively in surgical 
infections by Wright and his associates in New 
York, by Fine in Boston, and by Altemeier in 
Cincinnati. Wright was particularly impressed 
by its curative value in lymphogranuloma ven- 
ereum and in the treatment of peritonitis, non- 
specific ulcerative colitis, and serious urinary 
tract infections, and its prophylactic value in 
the preparation of the alimentary tract for sur- 
gical procedures. These results were confirmed 
by the other authors, but Fine encountered a 
number of patients who developed severe 
proctitis or colitis during oral therapy with 
chlortetracydine. This has been one of the 
chief drawbacks to its administration. 

Chlormuphenicol (Chloro^nycetin) . Chlor- 
amphenicol was found to have a range of ac- 
tivity similar to chlortetracydine. Furthermore, 
it possesses the unique quality of potency 
against the typhoid bacillus. The manufacturers 
w'ere able to analyze and synthesize this drug 
and found that the synthetic product can be 
made as cheaply as the biological. It wms not 
long, however, before reports came in of the 
development of aplastic anemia in patients 
following the use of chloramphenicol, and fear 
of this complication has limited its popularity 
inasmuch as other antibiotics have the same 
bacterial range, except for their impotency 
against the typhoid bacillus. 

Oxy tetracycline (Terramycin). Oxy tetracy- 
cline w^as soon found to have an action similar 
to chlortetracydine. In fact, organisms found 
to be primarily resistant to one or wffiich devel- 
oped resistance to one, were found to be re- 
sistant to the other. Further chemical analysis 
of these drugs demonstrated that they are 
similar chemically. 

Tetracycline. Tetracycline itself has a struc- 
’ ture common to both chlortetracydine and 
oxytetracycline. It first became commercially 
available in 1953, and it was soon demonstrated 
to have the same range of antibacterial activity 
as the other two, with perhaps fewer untoward 
side effects. 

Although chlortetracydine, chloramphenicol, 
oxytetracycline and tetracycline are potent 
against the pyogenic cocci and most of the 



66 Chapter 3. Surgical Bacteriology, Chemotherapy and Antibiotic Therapy 


gram-negative rods, the fact that they are all 
bacteriostatic rather than bactericidal requires 
the body to destroy the organisms after they 
have been held in check by the drug. This may 
result in a masking of the infection, which 
later flares up again when the antibiotic is dis- 
continued. Such an effect is more likely to 
occur in surgical infections than in medical 
infections, because the former are characterized 
by a local breakdown of tissues, resulting in a 
heavy concentration of organisms in the focus 
of infection with a thrombosis of blood vessels 
in the periphery of the lesion. With medical 
infections, however, where there is no local 
breakdown of tissues or thrombosed blood ves- 
sels, both the drug and the protective elements 
of the blood and tissues can reach the organisms 
wherever they happen to be. In general, there- 
fore, it may he stated that the so-called broad 
spectrum antibiotics mentioned above are more 
effective against medical infections than against 
surgical infections. Furthermore, with the ex- 
tensive use of these drugs, many organisms, 
particularly staphylococci, have developed re- 
sistance to them. 

Other Bactericidal Antibiotics. Three 
other bactericidal antibiotics, polymyxin, neo- 
mycin and erythromycin, have found a place 
for themselves in the treatment of surgical in- 
fections. Undoubtedly others will follow to 
strengthen still further the weak spots in our 
present armamentarium against bacteria dis- 
eases. 

Polymyxin, Polymyxin was first described 
by Benedict and Langlykke in the United 
States in 1947 and was so named by them. At 
almost the same time Ainsworth and his co- 
workers in England reported an antibiotic from 
a similar source, which they called aerosporin. 
These antibiotics are now considered to be 
identical. It is of interest and importance that 
they have the unique quality of being potent 
against most of the strains of the pseudomonas 
group of organisms, while they are relatively 
weak against the gram-positive cocci. Poly- 
myxin is handicapped because of its nephro- 
toxicity when given systemically, hut it is a 
potent bactericidal antibiotic when used locally 
and it may be used in solutions or ointments 
for local application without fear of irritating 
or toxic effects. This is fortunate because its 
action is most needed against surface-acting 
bacteria in wounds and burns, like the Pseudo- 
monas aeruginosa. If these organisms invade 


the blood stream, as they may, polymyxin may 
be used cautiously intramuscularly for a short 
period with the necessary safeguards, in spite 
of its toxicity. It is not absorbed Irom the 
alimentary tract. 

Neomycin. Neomycin was discovered by 
Waksman’s group in 1949 and has demon- 
strated its effectiveness not only against most 
strains of staphylococci but against most of the 
gram-negative aerobic rods, including the coli, 
aerogenes, and the proteus groups. Strangely 
enough, it is particularly v\'cak against strepto 
cocci and the clostridia. It is a potent bacteri- 
cidal antibiotic against susceptible organisms 
and can be used locally -in concentrations oC 
0.5 to 1.0 per cent in ointments and solutions 
to combat surface organisms, it has not only 
nephrotoxic properties but specific ncurotoxic 
action against the eighth cranial nerve, and 
thus its availability for systemic administration 
is curtailed. Neomycin is not absorbed from the 
alimentary tract and therefore, like bacitracin 
and polymyxin, is available for antibacterial 
activity against the intestinal bacteria. In fact, 
these three, when administered by mouth, 
cover almost completely the range of the intes- 
tinal flora, bacitracin being the most ])otent 
against the clostridia and intestinal cocci, neo- 
mycin against all of the grarn-negatit'c rods 
except the pseudomonas group, and polymyxin 
filling the gap left by the other two. 

Erythromycin, Erythromycin is [)r()duccd 
by one of the soil actinomycetes and was first 
reported by McGuire in 1952. It has a broad 
antibacterial spectrum and is believed to be 
bactericidal rather than bacteriostatic, lirythro- 
mycin is more potent against the gram-positive 
cocci and less effective against the gram- 
negative organisms than are the other broad 
spectrum antibiotics. It is potent against 
most of the strains of staphylococci that arc 
resistant to penicillin and the other anti- 
biotics. However, staphylococci have the ]M)wer 
to dev/elop resistance to erythromycin fairly 
rapidly. 

When applied in ointment form, erythro- 
mycin is effective against surface infections 
caused by susceptible organisms. Erythromycin 
is usually given by mouth, for it is absorbed 
from the alimentary tract, but intravenous ad- 
ministration is possible in the form of erythro- 
mycin glucoheptonate. It has demonstrated its 
ability to control invasive infections, when 
given either by mouth or by vein, but in 



Chemotherapy and Antibiotic Therapy of Surgical Infections 67 


patients with endocarditis requiring a long 
period of treatment, organisms may become 
resistant before cure has taken place. 

Erythromycin has the same untoward effects 
on the gastrointestinal tract as frequently result 
from peroral administration with the other 
broad spectrum antibiotics, namely, epigastric 
pain, nausea and diarrhea. According to one 
report these occur in approximately 20 per cent 
of cases. Other observers have thought that 
these side effects are less serious than with 
the other broad spectrum antibiotics, and in 
some cases prolonged treatment has been car- 
ried out without any difficulty. Erythromycin 
has been successful in controlling several cases 
of severe staphylococcal enteritis occurring dur- 
ing treatment with other antibiotics. 

GENERAL PRINCIPLES OF CHEMO- AND 

ANTIBIOTIC THERAPY IN SURGICAL 
INFECTIONS 

What are surgical infections? In its broadest 
sense the term “surgical infection” could apply 
to any type of infection in which operative 
intervention might be required during the 
course of therapy. However, in the present era 
of effective antibacterial chemotherapy, this 
definition would tend to exclude many cases of 
infections which formerly w^ould ha\^e been in- 
cluded, and w^hich would even now be deemed 
surgical if chemotherapy were found to be 
ineffective. For example, many cases of acute 
hematogenous osteomyelitis will now' respond 
to antibiotic therapy wdthout the necessity of 
surgical attack on the infected bone. How^ever, 
if treatment is delayed or improperly carried 
out or if the infecting organism happens to be 
resistant to the drug administered, a local 
abscess may form, or necrosis of the bone may 
occur, which will require resort to surgical pro- 
cedures similar to those which were routinely 
employed before the advent of chemotherapy. 
Therefore, it is desirable to define surgical in- 
fections in terms of their pathologic character 
rather than in terms of the indicated thera- 
peutic attack. A surgical infection, then, can 
be considered as one in which there is a gross 
alteration in tissue architecture which unless 
promptly aborted by chemotherapeutic means 
will lead to loss of substance, necrosis and sup- 
puration and, finally, to healing only through 
the formation of a scar. This definition is of 
more than academic interest because it recog- 
nizes the importance of proper timing and 


dosage in determining the ultimate necessity 
and scope of operative intervention. 

Characteristics of Susceptible Infectious- 

Infections susceptible to chemo- or antibiotic 
therapy tend to display the following charac- 
teristics: (1) The causative organism is not 
able to multiply in concentrations of the drug 
which can be transported by blood and lymph 
to the infected tissue; (2) the infected tissue 
retains its vascular communications with the 
general circulation and is therefore not yet 
metabolically isolated from the host; (3) in- 
hibitory factors derived either from bacterial or 
from tissue breakdowm and capable of nullify- 
ing the action of the drug are not present in 
significant amounts; (4) the host possesses a 
normal resistance to infection, that is, his re- 
sistance is not undermined by malnutrition, 
depletion of physiologic reserves or loss of hu- 
moral and cellular mechanisms required in 
combating infections. 

Susceptibility is of course a relative matter; 
the causative organism may be relatively resist- 
ant and yet respond to treatment if special 
efforts are made to bring high concentrations 
of the drug to the infected area. This is the 
principal basis for the employment of local 
transcutaneous methods in the treatment of 
localized soft tissue infections. Conversely, in- 
fections due to highly sensitive organisms will 
often respond to a drug dosage far below that 
customarily employed. Also, a lesion which 
might have been highly susceptible to the ther- 
apy at the outset may, in the course of the 
disease, become resistant when the local in- 
flammatory reaction leads to development of 
thick scar tissue or fibrinous envelopment. 

Characteristics of Resistant Infections. 

Resistant infections are those displaying con- 
ditions precisely the reverse of those enu- 
merated in the preceding paragraph: (1) The 
causative organism is not inhibited by the con- 
centration of the drug which can be directed to 
the infected tissue; (2) the infected tissue has 
undergone loss of its normal architecture, and 
its vascular and lymphatic communications 
have been largely obliterated so that the in- 
fected area has become metabolically isolated 
from the host; (3) substances are present which 
specifically antagonize or limit the effective ac- 
tion of the drug on the organisms in the area, 
and (4) the host is incapable of mobilizing an 
adequate defense against the infection. 

In resistant infections the outcome may be 



68 Chapter 3. Surgical Bacteriology, Chemotherapy and Antibiotic Therapy 


death of the patient, or his recovery may require 
that the surgeon resort to operative measures 
w'hich will supplement the combined action of 
the antibiotic drug and the host defense by 
draining off or excising a mass of infected fluid 
or tissue. 

RelatioEslilp between Surgical Procedures 
and Chemotlierapy. The indications for sur- 
gical intervention in the treatment of infections 
have changed remarkably during the period of 
development of antibacterial chemotherapy. At 
the time when the surgeon was equipped with 
only the scalpel, it was usual to incise or excise 
an infected part with very little hesitation. It 
gradually became apparent that incision was of 
relatively little value and that frequently it was 
actually productive of harm in the treatment 
of diffuse, spreading infections, such as cellu- 
litis, and the surgical treatment of infections 
about the face was considered to he especially 
dangerous and therefore contraindicated. At 
that time the surgeon frequently had to stand 
by helplessly and watch his patient become 
progressively overwhelmed by invasive infec- 
tion. If the patient lived long enough for a 
localized abscess to develop, surgical treatment 
was then carried out, and he usually recovered. 
However, when recovery took place, it was the 
patientis natural resistance rather than the sur- 
gical procedure itself which actually turned the 
tide, and the operative procedure was merely 
a valuable adjunct in the final process of 
recovery. 

The surgeon is no longer so helpless. Con- 
fronted with an invasive infection, he now ad- 
ministers the appropriate drug, preferably com- 
mencing it only after the diagnosis has been 
established, but sometimes necessarily guided 
as much by clinical evidence as by laboratory 
findings. If the infection falls into the suscep- 
tible category, the patient may recover without 
the development of a localized abscess, so that 
no operative intervention is needed. If an ab- 
scess does form, it will usually display itself 
after the invasive component of the infection 
has been brought under control, so that the 
patient is in satisfactory physical condition to 
withstand whatever operative procedure cir- 
cumstances may require. Furthermore, if the 
abscess is well localized and accessible, it may 
be possible to treat it satisfactorily by simple 
aspirations coupled with injections of the ap- 
propriate antibacterial agent into and around 
the ernty, so that disfiguring scars and pro- 
longed drainage are obviated. 


In the chronic granulomatOLis types of infec- 
tions, such us actinomycosis and tuberculosis, 
the balance of factors in the chemotherapeutic 
response is likely to he poorly adjusted, so that 
here a combined use of chemotherapy with 
surgical excision of the mass of the disease is 
frequenriy desirable. Formerly, the effectiveness 
of surgical excision was limited because of 
the tendency toward seeding oF the operative 
wound with organisms capable of regaining a 
foothold and leading to the recurrence of in- 
fection at the operative site, llowevcr, when 
antibiotic therapy is used in combination with 
surgical treatment in these conditions, lire like- 
lihood of infecting the operative field is sub- 
stantially reduced. 

Many situations arise in which surgical pro- 
cedures are needed in the treatment of infec- 
tions but where the objective is not the eradica- 
tion of the infection so much as the restoration 
of a normal functional and anatomic character 
to the infected part. An example of this is the 
use of surgical procedures in permitting re-ex- 
pansion of a lung which has become partially 
collapsed during chronic empyema. I lore the 
chemotherapeutic weapons arc quite able to 
control the infection as such, but, unless full 
expansion of the lung and obliteration of the 
empyema pocket are obtained, the patient is 
left at a physiologic disadvantage, and the in- 
fection is very likely to persist or recur in the 
pleural cavity. 

Perhaps the greatest contribution of chemo- 
therapy to operative surgery is the freedom 
which it gives to the surgeon to dismiss fear of 
infection as a decisive factor in selecting the 
surgical procedure best able to restore the pa- 
tient to his normal condition. In many varieties 
of abdominal and thoracic surgery, it was for- 
merly necessary to resort to physiologically un- 
desirable procedures simply because the one 
best suited to the patienth prompt functional 
restoration would be fraught with excessive risk 
of infection. Even though infections have not 
yet been eliminated as complications of surgical 
operations, the reduction of their incidence and 
severity has encouraged surgeons to employ 
many procedures which would formerly have 
been prohibitively dangerous. 

Principles of Dosage and Route of Admin- 
istration. General rules of dosage have al- 
ready been mentioned in the discussion of 
individual chemotherapeutic agents. Generally 
speaking, one aims to administer the amount 
which will provide maintained concentrations 



69 


Chemotherapy and Antibiotic Therapy of Surgical Infections 


of the drug in the infected area above the level 
of sensitivity of the infecting organism. In the 
case of the sulfonamides, bacitracin and strepto- 
mycin, it is necessary to keep in mind the toxic 
potentialities of the drugs and to balance a risk 
of toxic reactions against the urgency of using 
a particular drug. In the case of penicillin, the 
toxicity is ordinarily of little significance, so 
that one is restricted in dosage more by limits 
of transport and tissue concentration and by 
the knowledge that even maximal quantities 
of penicillin are ineffective in the treatment of 
infections due to totally insensitive bacteria. 
One must also keep in mind the steadily in- 
creasing number of persons who have devel- 
oped sensitivity to the drug. 

The route of administration of the drug will 
vary with circumstances. Whenever the infec- 
tion is diffuse or multicentric or is in a deep- 
seated structure, principal reliance must neces- 
sarily be placed on the systemic routes of 
administration, whether oral or parenteral. Fur- 
thermore, the systemic route is to be preferred 
in all cases if the patient displays a significant 
systemic reaction to the disease. However, when 
dealing with single and fairly well localized 
lesions, it may often be possible to employ 
direct or topical therapy and to avoid the neces- 
sity of systemic administration of the drug. The 
principal advantage of the latter type of treat- 
ment is economy in the drug cost and the 
avoidance of hospitalization. Very often the 
ideal method of treatment will be a resort to 
simultaneous use of systemic and topical routes. 

Systemic Treatment vs. Topical Treatment. 
Most surgical infections present two sets of 
problems: One is concerned with the invasive 
aspects of the infection when there is a ten- 
dency for the disease to spread out directly to 
contiguous uninfected tissues or indirectly, by 
blood stream and lymphatics, to remote struc- 
tures. The other is the localized component, the 
phlegmon or abscess, which develops locally at 
the primary site of the infection or at such 
secondary foci as may develop if the bacteria 
gain a firm foothold in other regions. Systemic 
chemotherapy is indispensable in combating 
the invasive aspects of surgical infections. The 
presence of an adequate concentration of an 
effective chemotherapeutic agent in the blood, 
lymph and extracellular fluid is the most im- 
portant factor in aiding the host in preventing 
peripheral spread of infection and in prevent- 
ing bacteria from gaining a foothold in second- 
ary foci. A favorable balance for full antibac- 


terial effectiveness exists in most acute invasive 
infections, and even the relatively low concen- 
trations of drug which are provided to the 
infected tissues by systemic treatment are capa- 
ble of halting bacterial invasion. The reason is 
that bacteria engaged in active invasion of a 
host are not locked up in fibrin or scar tissue or 
in tissue which has undergone necrosis, nor are 
they present in very large numbers, and the 
fluids which bathe them maintain a free ex- 
change with the systemic circulation. 

However, to the extent that localization has 
occurred, it follows that the area of bacterial 
activity tends to become isolated by an inflam- 
matory barrier from the systemic circulation. 
Furthermore, masses of organisms accumulate 
in clumps of fibrin, in thrombosed vessels and 
in tissue deprived of its blood supply. More- 
over, the leukocytes are less capable of exer- 
cising the normal antibacterial functions in the 
disturbed metabolic environment which a 
localized abscess represents, and the result is 
that chemotherapeutic agents administered by 
systemic routes are handicapped in their at- 
tack against organisms present within the local- 
ized component of the infection. 

It is usually possible to meet this limitation 
of antibacterial agents by resort to incision and 
drainage of the localized abscess. This permits 
removal of a major portion of the necrotic tissue 
and fibrin, improves the blood supply by 
releasing tension and results in healing by sec- 
ondary intention. However, incision and drain- 
age usually require some form of anesthesia, 
they often require hospitalization and inevi- 
tably result in the formation of a scar, which 
in some locations may be disfiguring or dis- 
abling. Therefore, it has seemed worthwhile 
to determine whether a high concentration of 
an agent such as penicillin or bacitracin deliv- 
ered directly at the site of an infection would 
be capable of terminating the local process 
without requiring resort to incision and drain- 
age. Experience has now established the 
effectiveness of such local or transcutaneous 
antibiotic therapy in dealing with localized 
lesions. Local therapy may often be used in 
combination with the administration of ade- 
quate doses of the drug systemically. The fol- 
lowing procedure is recommended. 

Well localized fluctuant processes with or 
without draining sinuses are aspirated with a 
19 gauge needle and irrigated with antibiotic 
solution until no more pus is obtained, the 
cavity being left filled with antibiotic solution, 



0 Chapter 3. Surgical Bacteriology, 

It not under tension. Slough and fibrin which 
ay resist efforts at irrigation at the first trcat- 
ent will usually be resolved by the second or 
ird treatment. The mechanism of this seem- 
gly accelerated resolution is not known. If 
)spitalization is necessary because of the size 
the lesion or the acutely ill condition of the 
Ltient, a small polyethylene plastic tube with 
2 mm. diameter and 1 mm. lumen is intro- 
iced into the abscess cavity through a tiny 
in opening. Through this tubing antibiotic 
lution is instilled frequently into the cavity, 
fost of the patients can be treated in the clinic 
ice or twice daily while remaining ambula- 
ry. An ointment containing the antibiotic 
^ent is applied to the surrounding skin to 
inimize contamination of adjacent hair folli- 
es and sweat glands. 

If, instead of a well-localized abscess, the 
rocess is acute cellulitis without a fluctant 
illection of exudate, it is carefully infiltrated 
ith the antibiotic drug, a 24 or 26 gauge 
eedle and a 2 cc. syringe being employed, 
’he usual local stinging caused by penicillin 
[ bacitracin is exaggerated when the tis- 
les are acutely inflamed. This discomfort is 
ready reduced by dissolving the penicillin 
rystals in 1 per cent procaine, the usual con- 
entration being 1000 to 5000 units per cubic 
entimeter. The local pain produced by infil- 
ration of bacitracin is greater than that of 
enicillin. Accordingly, bacitracin is dissolved 

1 2 per cent procaine or 1.5 per cent mono- 
aine hydrochloride, usually in a concentration 
if 500 units per cubic centimeter. The infil- 
ration is carried from the periphery toward the 
enter of the lesion and to a depth of about 
I to 3 cm. The infiltrated solution often flows 
)ut of the central skin sinuses, if such are 
present as in a carbuncle, bringing a little 
exudate with it. 

A few minutes after completion of this local 
treatment of either an abscess or cellulitis with- 
out an abscess, local discomfort is much re- 
duced, and this symptomatic relief persists long 
after the usual period of activity of the anes- 
thetic solution. 

Local treatment is performed once or twice 
daily, depending on the severity and acuteness 
of the situation. Such therapy is continued as 
long as the infectious element appears to be 
active, rarely more than two to three days. For 
some days after the acute inflammatory aspect 
of a large carbuncle or area of cellulitis has been 
controlled, dull red discoloration of the skin 


Chemotherapy and AntiDionc / tierapy 

and induration persist. These lade away slowly, 
with gradual resolution of the pathologic lesions 
of acute inflammation, leiiclcrness is not ]:)rcs 
ent. 

General measures arc not stressed, other than 
rest for the affected part, when possible. Hot 
wet dressings ordinarily arc not necessar\. 

It should he emphasized that this method ol 
treatment should be carried out with the same 
care and deliberation which would be employed 
in the performance of orthodox surgical treat 
ment and only by individuals cxpericnecc! in 
the recognition of complications ol soli tissue' 
infections, so that incision and drainage can he 
performed if the patient fails to respond to the 
conservative methods, hurlliermorc, it should 
again be emphasized that systemic therapy 
should always be combined with local treat 
ment whenever the patient displays e\'idc‘nec 
of invasive spread or shows any marked lebrile 
reactions or toxemia in association with the 
infection. 

Toxemia. Since the most conspicuous ef 
fects of the recently available antibacterial 
agents have been the repression of multi jdica- 
tion of sensitive organisms and since none of 
the drugs has displayed neutralizing elfeets 
against the best knowm exotoxins, such as those 
produced by Streplococcus keviolyticiis, Cory- 
nehactermm di plitheriae, Closiricliinn perfrht 
gens and Clostridium teiimi it has het'n gen- 
erally believed that these agents possess no 
direct antitoxic actions, llie prompt subsidence 
of signs of toxemia in patients ill with acute 
invasive infections has been attributed entirely 
to the repression of bacterial growth, in that 
toxin production ceases and toxemia disappears 
as soon as all of the circulating toxin has been 
neutralized. However, there is considcral)lc 
evidence that both the sulfonamides and peni- 
cillin may be capable of combating toxemia 
more directly than is implied iji the foregoing 
interpretation. Some years ago Carpenter 
brought forward evidence that animals eoidd 
be protected by sulfonamides against the dfeets 
of endotoxins derived from the gonococcus. 
These experiments were extended by several 
groups of investigators, and later Boor tuxl 
Miller showed that under certain conditions 
penicillin will aid in the resistance of animals 
to the endotoxins of several strains of gram- 
negative bacilli. 

It is now apparent that this phenomenon 
applies also to the highly toxic protein of 
Escherichia coll Large doses of penicillin ad- 



71 


Chemotherapy and Antibiotic 

ministeied to small animals concurrently with 
the injection of toxin derived from killed or- 
ganisms will protect the animals against doses 
several times the amount which is lethal for 
control animals. It is important to call attention 
to the possibility that this may be a significant 
mechanism in the therapeutic action of peni- 
cillin in peritonitis of intestinal origin, in which 
Escherichia coli is so commonly the predominat- 
Jng organism. Very possibly it explains the 
3-emarkably prompt clinical response displayed 
by patients critically ill with peritonitis follow- 
ing^ the administration of large doses of peni- 
cillin. Furthermore, it also provides further 
justification of the desirability of using large 
doses of penicillin, namely, 1 to‘3 million units 
per day in the treatment of these infections. 

RATIONALE OF ANTIBIOTIC THERAPY IN 
THE CONTROL OF SURGICAL INFECTIONS 

Inasmuch as a surgical procedure of itself 
will often bring the progress of a surgical in- 
fection to a standstill, it is at times difficult to 
be sure that the use of the antibiotics in addi- 
tion or as an adjunct to surgery will achieve 
this purpose any better than surgery alone. 
Some ^ time ago were suggested five criteria 
by which one could judge that the antibacterial 
agents are of some use in surgical infections. 
These criteria are met (1) when the antibiotics 
obviate the necessity for surgery entirely, (2) 
when they permit a less extensive surgical pro- 
cedure, (3) when they actually shorten the 
healing and recovery time, Cdj) when they 
permit a successful primary closure after re- 
moval of the focus of infection, which other- 
wise would not be possible, and (5) when they 
permit an earlier secondary closure than would 
otherwise be done. Further confirmation of the 
effectiveness of the antibiotics is demonstrated 
when the purulent exudate suddenly ceases or 
the wound cultures become negative. 

^ The knowledge of how best to use the anti- 
biotics and which ones to use in any given case 
is imperative. If penicillin were a panacea or 
the only antibiotic available, the decision would 
be easy, but the very multiplicity of antibac- 
terial agents, each with its respective advantages 
and disadvantages, makes the wise choice diffi- 
cult. Undoubtedly more antibiotics will be 
discovered and will complicate the picture still 
further. 

It requires continuous vigilance, but the 
rewards are gratifying when infections respond 
to specific therapy. This vigilance is essential 


Therapy of Surgical Infections 

because every accident and every surgical pro- 
cedure have the potentialities of infection and 
a large proportion of the patients on a general 
surgical service present problems of infections 
well established before they were admitted to 
the hospital. 

The conditions met by a surgeon which offer 
the opportunity for using antibiotics intelli- 
gently may be classified in two groups— those 
in which prophylactic measures are indicated 
and those requiring active measures. 

PROPHYLACTIC USE OF ANTIBIOTICS 

Clean Wounds. The surgeon is interested 
first of all in preventing infection in operative 
wounds. All of the minutiae of sterile technique 
have been developed with that end in mind— 
the autoclaving of dry goods and solutions, the 
boiling of instruments, the scrubbing of hands 
of the operating team, the masking of noses 
and mouths, the preparation of the operative 
field, the avoidance of air contamination, the 
use of silk and cotton for suture material, the 
gentle handling of tissues and careful hemo- 
stasis. All of these procedures should bring the 
incidence of wound infection in a clean field to 
less than 2 per cent and in serious infections to 
less than 1 per cent in any well-run operating 
room. 

What place have antibiotics in the pro- 
phylaxis of infection in clean wounds? Should 
50 patients receive an antibiotic or a combina- 
tion of antibiotics to prevent infection in one 
of them? No! Antibiotics should not be used 
with clean fields except for certain categories 
that will be mentioned below. To use anti- 
biotics in clean operations is an admission that 
the sterile technique in the operating room is not 
up to the requirements, and it is likely to drop 
to still lower levels if breaks in technique are 
not corrected, because the surgeon will say, 
"Oh, never mind. An antibiotic will take care 
of thatd^ 

There are, however, certain procedures at- 
tending which infection, if it occurs, is a very 
serious matter. These are operations on the brain 
and on the heart. Their performance often is 
lengthy, and, therefore, the chance of aic con- 
tamination is increased. In a somewhat lower 
category, from the point of view of the fre- 
quency of infection, are the long plastic 
procedures on the neck, chest and breast. 

What antibiotics should be employed in 
these operations, and how should they be used? 
The condition "with which the surgeon has to 



Chemotherapy and Antibiotic Therapy of Surgical Infections 71 


ministered to small animals concurrently with 
the injection of toxin derived from killed or- 
ganisms will protect the animals against doses 
several times the amount which is lethal for 
control animals. It is important to call attention 
to the possibility that this may be a significant 
mechanism in the therapeutic action of peni- 
cillin in peritonitis of intestinal origin, in which 
Escherichia coli is so commonly the predominat- 
ing organism. Very possibly it explains the 
remarkably prompt clinical response displayed 
by patients critically ill with peritonitis follow- 
ing the administration of large doses of peni- 
cillin. Furthermore, it also provides further 
justification of the desirability of using large 
doses of penicillin, namely, 1 to' 3 million units 
per day in the treatment of these infections. 

RATIONALE OF ANTIBIOTIC THERAPY LN 
THE CONTROL OF SURGICAL INFECTIONS 

Inasmuch as a surgical procedure of itself 
will often bring the progress of a surgical in- 
fection to a standstill, it is at times difficult to 
be sure that the use of the antibiotics in addi- 
tion or as an adjunct to surgery will achieve 
this purpose any better than surgery alone. 
Some time ago were suggested five criteria 
by which one could judge that the antibacterial 
agents are of some use in surgical infections. 
These criteria are met (1) when the antibiotics 
obviate the necessity for surgery entirely, (2) 
when they permit a less extensive surgical pro- 
cedure, (3) when they actually shorten the 
healing and recovery time, (4) when they 
permit a successful primary closure after re- 
moval of the focus of infection, which other- 
wise would not be possible, and (5) when they 
permit an earlier secondary closure than would 
otherwise be done. Further confirmation of the 
effectiveness of the antibiotics is demonstrated 
when the purulent exudate suddenly ceases or 
the wound cultures become negative. 

The knowledge of how best to use the anti- 
biotics and which ones to use in any given case 
is imperative. If penicillin were a panacea or 
the only antibiotic available, the decision would 
be easy, but the very multiplicity of antibac- 
terial agents, each with its respective advantages 
and disadvantages, makes the wise choice diffi- 
cult. Undoubtedly more antibiotics will be 
discovered and will complicate the picture still 
further. 

It requires continuous vigilance, but the 
rewards are gratifying when infections respond 
to specific therapy. This vigilance is essential 


because every accident and every surgical pro- 
cedure have the potentialities of infection and 
a large proportion of the patients on a general 
surgical service present problems of infections 
well established before they were admitted to 
the hospital. 

The conditions met by a surgeon which offer 
the opportunity for using antibiotics intelli- 
gently may be classified in two groups-those 
in which prophylactic measures are indicated 
and those requiring active measures. 

PROPHYLACTIC USE OF ANTIBIOTICS 

Clean Wounds. The surgeon is interested 
first of all in preventing infection in operative 
wounds. All of the minutiae of sterile technique 
have been developed with that end in mind— 
the autoclaving of dry goods and solutions, the 
boiling of instruments, the scrubbing of hands 
of the operating team, the masking of noses 
and mouths, the preparation of the operative 
field, the avoidance of air contamination, the 
use of silk and cotton for suture material, the 
gentle handling of tissues and careful hemo- 
stasis. All of these procedures should bring the 
incidence of wound infection in a clean field to 
less than 2 per cent and in serious infections to 
less than 1 per cent in any well-run operating 
room. 

What place have antibiotics in the pro- 
phylaxis of infection in clean wounds? Should 
50 patients receive an antibiotic or a combina- 
tion of antibiotics to prevent infection in one 
of them? No! Antibiotics should not be used 
with clean fields except for certain categories 
that will he mentioned below. To use anti- 
biotics in clean operations is an admission that 
the sterile technique in the operating room is not 
up to the requirements, and it is likely to drop 
to still lower levels if breaks in technique are 
not corrected, because the surgeon will say, 
‘'Oh, never mind. An antibiotic will take care 
of that.” 

There are, however, certain procedures at- 
tending which infection, if it occurs, is a very 
serious matter. These are operations on the brain 
and on the heart. Their performance often is 
lengthy, and, therefore, the chance of air con- 
tamination is increased. In a somewhat lower 
category, from the point of view of the fre- 
quency of infection, are the long plastic 
procedures on the neck, chest and breast. 

What antibiotics should be employed in 
these operations, and how should they be used? 
The condition with which the surgeon has to 



72 Chapter 3. Surgical Bacteriology, Chemotherapy and Antibiotic Therapy 


deal is a wound with relatively few organisms 
on freshly cut surfaces. The ideal treatment is 
a fine spray of 5 to 10 cc. of the antibiotic into 
all crannies of the wound during closure. Thus 
direct contact with contaminating organisms 
can be obtained. Furthermore, the best anti- 
biotic is one that is bactericidal. By using such 
an antibiotic the organisms can be killed di- 
rectly and are given no chance to gain a foot- 
hold. They are not merely held in check as 
they would be by a bacteriostatic agent requir- 
ing the bacteria to be destroyed by the body 
defenses. 

The most common contaminating organisms 
in clean operations are the staphylococci from 
the air and from the skin of the patient. If the 
operating team personnel does not adequately 
mask the nose as well as the mouth, another 
abundant source of staphylococci is open to the 
sterile field. Many of these staphylococci are 
resistant to penicillin but are susceptible to 
bacitracin or neomycin. A mixture of these two 
antibiotics will be effective against most opera- 
tive wound contaminants and an aqueous or 
saline solution containing 1000 units of baci- 
tracin per cubic centimeter and 1 per cent neo- 
mycin is recommended for local application. 
On brain surfaces, bacitracin is much less toxic 
than are other antibiotics, and this fact makes 
it preferable as a prophylactic in neurosurgical 
procedures. 

Contaminated Fields. There is a clearer 
indication for the use of antibiotics prophylacti- 
cally in contaminated fields of operation. Bac- 
teria on mucous membrane surfaces of the body 
cannot be destroyed or reduced in number as 
readily as they can be on the skin. Operations 
that expose the tissues to contamination from 
these sources have, therefore, a greater chance 
of becoming infected. The incidence of infec- 
tion in these fields may be 20 to 25 per cent in 
a well-ordered operating room, if antibiotics 
are not used. It is reasonable to give antibiotic-s 
to four or five patients to prevent infection in 
one. This applies to operations on the eye, ear, 
nose, throat, mouth, esophagus, stomach, duo- 
denum, jejunum, ileum, colon, vagina and 
penis. 

The organisms that commonly contaminate 
operative wounds made on the nose are sta- 
phylococci and nonhemolytic streptococci. On 
the mouth and esophagus they are the non- 
hemolytic and anaerobic streptococci, and, 
where there is a chronic pyorrhea, spirochetes 


and fusiform bacilli. The stomach with nor- 
mally acid gastric juice often yields sterile 
cultures because of the acidity of that secretion. 
When organisms are found in the stomaeb or 
duodenum, they are usually the nonhemolytic 
streptococci, which are able to persist longer 
than other organisms in the acid environment 
and often pass into the duodenum, lliesc 
species are also present in the jcjuniim, and 
here the gram-negative rods of the coli group 
begin to appear and a little larthcr down, the 
Clostridia, including the Welch bacilli. These 
three groups increase in number and variety 
from above downward; they arc in greatest 
concentration in the lower ileum. Wlien they 
pass the ileocecal valve into the colon, they 
begin to die in great numbers, so that when 
the stool is passed out of the rectum, although 
one-third of the mass is made up of bacterial 
bodies, most of them are dead. 

Operations on the stomach and intestine have 
been carried out for many years through a 
clean abdominal wall. The operative field is 
only contaminated when the lumen is entered. 
Contamination can be minimized by various 
closed methods of anastomosis, but with the 
open methods now widely used, contamination 
varies greatly according to the care taken to 
prepare the bowel beforehand, cither mechani- 
cally or chemically, and the care taken to pre- 
vent spillage. In recent years more and more 
procedures on the alimentary tract are carried 
out through thoracic or thoracoabdominal in- 
cisions, thus exposing the mediastinum and the 
pleural cavities to contamination. Often leaks 
from esophageal or esophagogastric anasto- 
moses, duodenal stumps, gastroenterostomies, 
or enteroenterostomies are attributed to faulty 
suturing. However, contaminating bacteria are 
more often responsible for the failure of these 
anastomoses to heal, and this results in leakage. 

It is, therefore, the responsibility of the sur- 
geon to use every means available to minimize 
the contamination of the operative field when- 
ever he is working along the alimentary tract. 
Bacitracin is particularly useful in this region, 
because it is potent against the nonhemolytic 
streptococci, the anaerobic streptococci and the 
spirochetes of the mouth, and it seldom if 
ever causes any allergic reaction in the mouth » 
For action further along the alimentary tract, 
bacitracin requires the addition of an antibiotic 
potent against the gram-negative rods, and 
here neomycin seems to serve well. Neomycin 



73 


Chemotherapy and Antibiotic Therapy of Surgical Infections 


is weak against the streptococci and clostridia, 
but it is potent against most strains of Escheri- 
chia colt and particularly against proteus, which 
is resistant to almost all of the other antibiotics. 

Both bacitracin and neomycin are hacterh. 
ddal and are compatible with each other. Their 
synergistic action has been demonstrated many 
times, but never antagonism except in very 
low dilution. Tablets containing the combina- 
tion of bacitracin and neomycin are available 
commercially. They may be dissolved slowly in 
the mouth once every four or six hours to ob- 
tain the maximum effect in the mouth and 
esophagus or in the stomach. If the effect is 
desired in the lower intestine, four tablets 
should be swallowed every four or six hours. 
As neither of these antibiotics is absorbed, they 
continue their maximum action all along the 
alimentary tract. There is no need to fear any 
systemic toxic reactions. When cultures are 
taken from the esophagus or stomach or at the 
site of bowel resection, sterile cultures are often 
obtained after bacitracin and neomycin have 
been administered, as described above, for 
forty-eight or seventy-two hours preceding 
operation. If growth occurs it is scant, indicat- 
ing great reduction of viable organisms. Neither 
staphylococcic nor proteus enteritis follows their 
use in this manner. 

Neomycin has been used alone by Poth in 
intestinal antisepsis with good reports of its 
effectiveness, but its weakness against the 
Clostridia and the intestinal streptococci, both 
hemolytic and nonhemolytic, leaves a gap in 
the coverage of the intestinal organisms. This 
gap is closed by bacitracin. Of 29 strains of 
Clostridium perfringens recently tested, all 
were susceptible to bacitracin but only 10 per- 
cent to neomycin. 

Chlgrtetracycline, oxy tetr acyclin e, and chlor- 
amphenicol have all been used, and favorable 
results have been reported. These three anti- 
biotics, however, are often not well tolerated in 
the mouth and, therefore, are not available for 
action on mouth organisms. All of them are 
partially absorbed from the intestine, and the 
amount available to inhibit the multiplication 
of organisms in the lower intestine is uncertain. 
Furthermore, they frequently cause gastroin- 
testinal upsets, with nausea and diarrhea, and 
must often be discontinued on that account. 
Mondial superinfections occur in some patients 
treated with chlortetracycline, oxytetracycline, 
or chloramphenicol, and the proteus bacilli and 


Micrococcus pyogenes var. aureus may multi- 
ply prodigiously in the bowel. For these rea- 
sons, these three so-called broad spectrum anti- 
biotics are not optimal for this purpose. 

At the time of operation, the surgeon should 
take a culture from the lumen of the ali- 
mentary tract at the site of operation, wherever 
that may be, so that he will know within 
twenty-four hours what organisms, if any, 
have contaminated the operative field. If any 
organisms are still viable in the lumen of the 
gut, the surface of the tissues at the level of 
operation will be contaminated by these resid- 
ual bacteria. One must assume in any given 
case that some of the intestinal organisms may 
have contaminated the operative site. There- 
fore, an added safeguard is accomplished by 
spraying the contaminated field with 20,000 
units of bacitracin and 1 per cent neomycin in 
20 cc. of water or sodium chloride solution to 
give a wide coverage of the intestinal flora. 
If this is done, there would seem to be no clear 
indication for the postoperative systemic ad- 
ministration of the antibiotics, although this 
has its advocates and is widely practiced, a 
combination of penicillin and streptomycin 
being most often used. 

If the cultures taken at the operative site 
yield organisms resistant to the antibiotics that 
have been used, a change should be made after 
twenty-four or forty-eight hours to the anti- 
biotic or mixture of antibiotics that have been 
demonstrated to have the greatest activity 
against those particular organisms. Such treat- 
ment should then be given systemically, if pos- 
sible, because the opportunity for local ad- 
ministration has been passed. 

Before operations on the vagina, cultures 
should always be taken, and the sensitivities of 
the bacteria found should be determined. Then, 
during the operation, the operative field should 
be sprayed with the antibiotic that is most po- 
tent against the contaminating organisms. 

Another important field for the prophylactic 
use of the antibiotics comprises civilian acci- 
dent wounds, burns and gunshot wounds. 
These are all contaminated, usually with a mix- 
ture of organisms. Dirty accident and gunshot 
wounds should always be thoroughly debrided 
and the debrided tissues, blood clot, dirt and 
other foreign bodies sent to the laboratory for 
culture so the surgeon may be forearmed with 
knowledge of which organisms are present and 
of their sensitivities, should infection develop. 



74 Chapter 3. Surgical Bacteriology, Chemotherapy and Antibiotic Therapy 


Some residual contaminating organisms are al- 
ways left on the surface, but they arc not deep 
in the tissues of the wound, if less than four 
hours old. This offers the best opportunity for 
obtaining close contact of these organisms with 
some potent bactericidal antibiotics. A combina- 
tion of bacitracin, 1000 units per cubic centi- 
meter, and 1 per cent neomycin covers most of 
the organisms that may be expected in these 
wounds. The mixture should be sprayed lib- 
erally over the surface and into all nooks and 
crannies. This local application is more im- 
portant than the systemic use of antibiotics in 
these cases. It should be remembered that the 
organisms are on the surface and not in the 
tissues, unless the wound is four or more hours 
old. 

Wounds of the scalp, face or hands may be 
closed after local application of antibiotics. In 
other areas, the wounds may be left open, 
tamponed with China silk and packed with 
fine-meshed gauze wet with the antibiotic mix- 
ture. If on the next day the culture report indi- 
cates a change in antibiotics, they should be 
applied. If the cultures show no important 
pathogens and the wound remains clean, a late 
primary or early secondary closure may be 
done. If the cultures reveal important patho- 
gens, the appropriate antibiotic or combination 
of antibiotics may be used systemically. The 
wound should then be left open until the 
pathogenic organisms have been eliminated. 

The contamination of burns is similar to that 
of wounds except that the organisms are gen- 
erally more numerous and are distributed over 
a larger area. Again, it should be remembered 
that immediately after the burn, the organisms 
are on the surface only and that this offers the 
best opportunity for bringing the most potent 
antibiotics into contact with them. Again cul- 
tures should he taken to determine within 
twenty-four or forty-eight hours the organisms 
with which the surgeon has to deal. A mixture 
of antibiotics should be applied to the surface 
as soon as the cultures have been taken and 
without waiting for the culture report. The an- 
tibiotic treatment should be modified later, if 
necessary, according to the results of the cul- 
tures. 

One more situation in which antibiotics may 
be used prophylactically occurs in cases of elec- 
tive amputation of an extremity for gangrene. 
Preliminary cultures and, sensitivity tests will 
indicate the most potent antibiotics against 
the organisms present in the gangrenous lesion. 


It must be assumed that organisms arc nio\ ing 
Lip the lymphatics to or beyond the le\ cl of am- 
putation. It is good practice to take eultures at 
the level of amputation and then to spra\' the 
surfaec with the antibiotic indicated hv the 
preliminary culture before closing the wound. 
If the infection in the distal area is severe and 
the organisms found on culture are ol' par 
ticular virulence, the wound should be left 
open until the results of the cultures from the 
level of amputation are known. If the cultures 
are negative, a delayed primary or early sec- 
ondary closure may be clone. If the cultures are 
positive, local treatment with the antil)iotic 
should he continued and systemic treatment 
should be instituted because of the proI)ahilit\' 
that the infection has already gone hevond tlie 
cut surface. 

ACTIVE TREATMENT OF SURGICAL INM-.C 
HONS 

It goes without saying that the anlihiolies 
will not be effective in controlling anv in fee 
tion unless the organism is sensitive to the anti- 
biotic used. This sensitivity can be determined 
only by culture studies in the !al)(>raiory. It 
cannot be done by guesswork. [a*om the 
previous course of the infection or the tirca 
involved, many experienced surgeons may be 
able to guess the most likely causative sjx.‘cies 
of bacteria, but they cannot guess, w-ith tiny 
measure of certainty, the susceptibility of the 
organisms to any given antibiotic. 

The development of resistant strains of the 
common organisms, first noted with the sttiphy- 
lococci against penicillin and recently with 
other organisms against all of the antii)i()tics, 
makes it imperative that these tests be clone. 
It is more important to determine the sensitivi- 
ties of the organisms than to name or classify 
the organisms. The blood agar plate method 
using filter-paper disks wet with the proper 
dilution of the different antibiotics is the 
simplest and most reliable, and the dilutions can 
be adjusted so that the results arc of real clinical 
significance. The laboratory should routinely 
test the sensitivity c)f every culture siraiiltunc- 
ously against the five antibiotics most com- 
monly used, penicillin, bacitracin, streptomycin, 
tetracycline and neomycin. A prclinninary re- 
port may be made after overnight culture. If 
any organisms are resistant to these five, further 
studies are made with chlortetracycline, clilor- 
amphenicolj polymyxin and erythromycin. 



75 


Chemotherapy and Antibiotic 

CHRONIC AND ACUTE INFECTIONS 

There is a great diversity of well-established 
surgical infections. Chronic surgical infections 
may develop from any acute infection. An ar- 
bitrary time division between acute and 
chronic cases is thirty days. In many instances, 
chronic surgical infections have been inade- 
quately and improperly handled without a 
proper bacteriologic study or without treatment 
with an antibiotic potent against the causative 
organisms. Today, no acute surgical infection 
should ever become chronic while under the 
intelligent care of a competent surgeon. Sur- 
geons dealing with infections should be bac- 
teriologically minded and should keep in mind 
what and where bacteria are involved in the 
process and how they can be reached and de- 
stroyed by the use of both the knife and anti- 
bacterial agents. Today surgery may be obvi- 
ated in many cases, and this is usually to the 
patient's advantage. 

In acute cases, if possible, a specimen of 
exudate should be taken by surface swabbing, 
or by aspiration, for smear and culture before 
instituting any drug treatment. After the cul- 
ture has been taken, however, drug treatment 
should not be delayed. An immediate examina- 
tion and report on the smear will give some hint 
regarding the nature of the organism. The sur- 
geon must use his judgment as to wTich anti- 
biotic is most likely to succeed and how it can 
best reach the organisms. If, on the next day, 
the culture indicates that his judgment has been 
correct, the original antibiotic should be con- 
tinued, but, if the culture indicates a change, 
that change should be made at once. 

In chronic cases, a careful bacteriologic analy- 
sis should be made before starting treatment 
because there is usually a mixture of organisms 
present which have resisted previous anti- 
biotic treatment. In established infections, the 
organisms are not merely on the surface but 
deep in the tissues, possibly in thrombosed 
blood vessels or in the blood stream. In such 
cases, the local application of the antibiotic may 
not contact the organisms; the antibiotic should 
then be given systemically in such doses and at 
such frequent intervals that it will reach the 
spreading periphery of the infection. In many 
established infections, however, local applica- 
tion is sufficient and the antibiotic can be 
brought into contact with the organisms in 
much higher concentration than by means of 
systemic treatment and without any damage 


Therapy of Surgical Infections 

to the local tissues. In this respect,, the bac- 
tericidal antibiotics such as penicillin, baci- 
tracin, polymyxin, streptomycin and neomycin 
are far superior to the bacteriostatic antibiotics 
and to the sulfonamides. 

In many chronic infections there is necrotic 
tissue or scar tissue, which requires surgical re- 
moval. Ideal treatment calls for the complete 
removal of all grossly infected tissues. Very 
often, however, a compromise is necessary in 
areas where loss of tissue would interfere with 
proper function or result in deforming scars. In 
such circumstances, the surgeon has to be con- 
tent with incision and drainage, relying upon 
the living tissues with the aid of local anti- 
biotics or enzymes to separate ofE the dead por- 
tions after the operation. 

Physiologic disturbances are often present 
in patients with chronic infections. These in- 
clude loss of blood volume, as well as protein 
or electrolyte imbalance, and require proper ad- 
justment before the infection can be brought 
under control. 

In cases of surgical infection caused by the 
hemolytic streptococcus, the hemolytic Micro- 
coccus pyogenes var. aureus, and organisms of 
the coli, proteus and pseudomonas groups, sep- 
ticemia may he present and the bacteria may be 
repeatedly recovered from the blood stream. 
In such cases, it behooves the surgeon to seek 
and remove, if possible, or drain the distribut- 
ing focus, and to give systemically that antibiotic 
to which the organism is most sensitive. It is 
particularly important in cases of acute osteo- 
myelitis that the most potent antibiotic be given 
early, within four days, to prevent the break- 
down of the bone and its very unfortunate 
sequelae. 

SYNERGISM AND ANTAGONISM 

When faced with a fulminating acute infec- 
tion or a long-standing chronic one, some sur- 
geons give two or three antibiotics as a shotgun 
remedy without any consideration of bacterial 
cultures or sensitivity tests and without a 
thought concerning the possibility of antag- 
onism of one antibiotic toward another. The 
surgeon often excuses himself by saying, ‘If 
one antibiotic does not stop the infection, one 
of the others will.'" This practice is certainly 
to be condemned as being unscientific, usually 
ineffective, and often harmful. 

When primary cultures and sensitivity tests 
show a single organism and a single potent 



76 Chapter 3. Surgical Bacteriology, Chemotherapy and Antibiotic Therapy 


antibiotic out ol five or more tested, that anti- 
biotic should be used alone. If there is a mix- 
ture of organisms, as is so often the case in 
chronic infections, the susceptibility of each 
one should be tested and the most potent anti- 
biotic used against each organism, provided the 
antibiotics are not antagonistic to one another. 

Jawetz and his co-workers have found that 
synergism often exists between two of the bac- 
tericidal, or group i, antibiotics (penicillin, 
bacitracin, streptomycin, polymyxin and neo- 
mycin) and between antibiotics of the bacterio- 
static, or group 2, antibiotics (chlortetracycline, 
oxytetracycline and chloramphenicol). How- 
ever, antagonism often results, if a member of 
group 2 is combined with a member of group 
1. This does not always hold true and cannot 
be predicted with certainty. It depends a great 
deal on the susceptibility or resistance of the 
organisms. It should he kept in mind, however, 
when antibiotic combinations are used clini- 
cally. Combinations of the two groups should 
be avoided unless synergism has been demon- 
strated in vitro. Further study is required on 
this important problem, and it will need to be 
continued as new antibiotics become available. 

Successful treatment of surgical infections re- 
quires, on the part of the surgeon, the knowl- 
edge of the natural occurrence of bacteria in 
relation to the body, their potentialities and 
predilections, their behavior after gaining a foot- 
hold in the body, and the proper methods and 
timing of certain surgical procedures. Of equal 
if not greater importance for success in treat- 
ment is a knowledge of the causative and asso- 
ciated organisms and their susceptibilty to the 
available antibiotics and the proper methods 
of their application. 

The natural course of surgical infections may 
be profoundly altered or brought to a complete 
standstill by the use of the appropriate anti- 
biotic or combination of antibiotics in addi- 
tion to the proper surgical procedure. Many 
times in acute cases surgery may be completely 
obviated or its extent curtailed. In chronic sur- 
gical infections a surgical procedure is often 
required for the removal of dead or scarred 
tissue, and profound physiologic disturbances, 
which n\ay have occurred during the course of 
the infection, must be readjusted. 

The advances and developments in the man- 
agement of surgical infections have been most 
striking and remarkable during the course of 
the last half century. However, success in the 


treatment of surgical infections cannot be at- 
tained by the indiscriminate use of the anti- 
biotics, which is not only unsdcnlific but po- 
tentially dangerous. The patient can only c!cri\’e 
the fullest benefit from knowledge of recent 
developments in this field, if the causaii\x' or- 
ganisms and their sensitivities arc determined 
promptly in the bacteriologic laboratory, en- 
abling the surgeon to apply specific trcatmeiu 
at the earliest opportunity. The disciplines of 
surgery and bacteriology should maintain the 
closest possible cooperation, if continued prog- 
ress is to be made in the prevention and control 
of surgical infections. 

APPLICATION OF PRINCIPLES OF CUEMO- 

AND ANTIBIOTIC THERAPY IN 
SURGICAL INFECTIONS 

The importance of the relationship between 
bacteriology and surgery can be emphasized 
by a discussion of examples of surgical infec- 
tions which illustrate the importance of pro- 
phylaxis, the accurate identification of the 
offending bacterial organisms and the specific 
use of chemo- and/or antibiotic therapy, d o 
this end, chronic undermining ulcer, infectious 
gangrene of the skin and subcutaneous tissues 
and tetanus are described in the following 
paragraphs. 

CHRONIC UNDERMINING ULCER 

In 1935 a chronically progressive ulceration 
of the skin was described as a clinical and bac- 
teriologic entity. This disease is fortunately rare 
but is of importance because of the extent of its 
involvement of the surface of the body, f)e- 
cause of its stubborn resistance to the usual 
forms of treatment and because of the fre- 
quently fatal outcome. 

Clinical Course, The disease begins gradu- 
ally in the vicinity of an incised infected lymph 
gland, in an operative wound associated with 
the intestinal or the genital tract or in an acci- 
dental wound. The lymph gland group occurs 
in the neck, axilla or groin. The postoperative 
type generally follows an operation on the in- 
testine, appendix or genital tract. The third 
type may occur anywhere on the body surface 
following an accidental wound. 

What appears to be an ordinary infection 
fails to follow the usual course of healing. 
Improvement, which may have been present 
in the early stages, gradually ceases. The skin 
margins slowly become undermined, with lique- 
faction of the subcutaneous fat and connective 



77 


Chemotherapy and Antibiotic Therapy of Surgical Infections 



Figure 4. Chronic undermining ulcer involving pelvis, sacral region and thigh. Note the extensive under- 
mining with deep sinus formation and daughter ulcers with cribriform openings in the skin and bridges 
between. No gangrene. 


tissue and inversion of the margins. There is 
no gangrene of the shin, hut as the undermin- 
ing progresses, areas in the neighboring skin 
may take on a dull red or bluish appearance. 
It is then found that the undermining has ex- 
tended beneath these areas and the skin has 
become thinned out as if it were being lique- 
fied from beneath. After a number of weeks a 
small opening generally appears in these thin 
areas. These secondary openings gradually en- 
large and may extend until they fuse with the 
original ulcer, or they may leave a bridge of 
skin in between, which becomes epithelized 
on its deep surface. In lower abdominal lesions 
the undermining frequently spreads down to- 
ward the groin or toward the pubic region, ex- 
tending into the vulva, into the scrotum or be- 
neath the crease of the groin into the thigh. In 
these regions it may burrow deeply, dissecting 
beneath the muscles and forming deep sinuses 
into the pelvis. In certain places where the skin 
is more firmly attached to the deep tissues, such 
as around the umbilicus or the crest of the 
ilium, the undermining may stop. Sometimes 
there are portions of the margin where under- 
mining does not take place, and healing may 
proceed with a new growth of skin. Then in- 
stead of progressing steadily, the margin of 
new epithelium may suddenly stop advancing 
or may rapidly melt away. Occasionally these 
ulcers develop on the leg after a minor injury. 
In such cases there is always some undermining 
of the skin margins, but usually they do not 
undermine extensively in this region. 

Pain is usually moderate but may be excruci- 
ating. Fever may rise to 101° and 103° F. 
daily for a long time or may swing to lower 
levels. During the period of fever the patient 


is usually greatly prostrated. In the course of 
time the lack of response to treatment fre- 
quently brings great discouragement and 
gradually breaks down the patients morale. 
This may reach such a degree that the patient 
expresses a desire to commit suicide. After 
months or years of suppuration the lesion may 
gradually heal spontaneously, but if improper 
treatment is given, it usually burrows deeply 
and causes death either by erosion of a large 
vessel or by the gradual development of amyloid 
degeneration of the liver, spleen and kidneys. 

Etiology. The essential organism in this 
infection is a hemolytic streptococcus which 
prefers an anaerobic environment. Its imme- 
diate source is probably either the intestinal 
tract or the vagina. In many cases it can be 
obtained only by anaerobic cultivation, and is 
therefore frequently missed with the routine 
aerobic methods. From some lesions it may be 
obtained aerobically, but it can almost always 
be demonstrated to grow better anaerobically 
than aerobically. The organism undoubtedly 
belongs to the group of '"anaerobes by predilec- 
tion' of Prevot, although he did not describe 
any hemolytic varieties. The term '"micro- 
aerophilic” seems to be preferable. Beaux has 
confirmed the specific bacterial etiology of this 
disease. 

Treatment. Practically every known form 
of general and local medication and physical 
modality has been tried in these cases. There 
has been some evidence of improvement with 
the use of maggots, and there has been at least 
one spontaneous recovery (after twenty-six 
months following the use of ultraviolet light). 
The most effective treatment, however, and one 
that will almost always effect a cure, provided 


78 Chapter 3. Surgical Bacteriology, Chemotherapy and Anlihioiic llicrapy 


the medication can be apfdieci to every part of 
the wound, is the daily use of medicinal grade 
zi]ic peroxide produced by the Du Pont Chemi- 
cal Company and distributed by Mallinckrodt. 
This is a white powder containing about 50 
per cent of ZnOo and lesser proportions of 
ZnO, ZnCO;.; and Zn (OH) 2 - The active in- 
gredient here is the zinc peroxide, which pro- 
vides a highly oxygenated environment which 
at first inhibits and then actually kills the or- 
ganisms in the lesion or modifies their cultural 
characteristics to such an extent that the infec- 
tion almost at once ceases to advance and starts 
to retrogress. The powder— which must be the 
‘medicinal grade,” actively generating oxygen 
when suspended in sterile distilled water- 
should be sterilized in small quantities in a drv 
sterilizer at 140° C. for four hours and sus- 
pended in its own volume of sterile distilled 
water just before use. This gives an even, 
creamy suspension which may be applied with 
the aid of a syringe and catheter to all parts ol 
the ulcerated surface and sinuses, it is essential 
that the medicine reach every nook and crann\' 
of the infected area, for the lesion may spread 
in any region which is not reached. Any un- 
approachable regions should be opened widely. 
The ulcerated portion should be covered with 
fine-mesh gauze or absorbent cotton soaked in 
the suspension of zinc peroxide. This in turn 
is covered with a layer of cotton soaked in dis- 
tilled water. The whole region shoidd then be 
sealed with gauze impregnated with petro- 
latum or ZnO ointment to prevent evaporation. 
After twenty-four hours the dressing comes 
away easily without sticking to the wound. The 
whole wound should be irrigated with sterile 
saline solution or distilled water and a fresh 
suspension applied. When the undermined 
flaps have become sealed down, skin grafts may 
be applied to cover over the remaining defect. 

Sulfadiazine may also be given if the pa- 
tient can tolerate it In some cases there is 
hypersensitivity to this drug. In some of the 
simpler cases, this drug alone may effect a cure, 
but a combination of sulfadiazine by mouth, 
if tolerated, with zinc peroxide locally will re- 
sult in the most rapid healing. Rhoads and 
others have confirmed the favorable response of 
these ulcers to zinc peroxide treatment. Leacock 
has reported success with penicillin, but in 
a number of these cases, penicillin has been used 
without benefit, possibly because of the inacti- 
vation of the penicillin by organisms capable of 


producing pcnicilliiiast\ slii h as ihc iu'inbit’ 
gram-iicgativc lods which arc I iccjiiciii l\ pics 
ent as sccondarv contaniinaiils in llic'sc lesions 

Bacitracin is more clhvlixc than penicillin in 
the treatment of tin’s inb'ctinn bccaiisi' il is imi 
inhibited hy the pcmicillinasc preduecis. 

ll()wc\cr, bacitracin will net euiaa the disease 
without a prcliminar) surgical excision nf all 
of the undermined nieas and the iinohcd 
lymph glands. It should then be administiacd 
both system ieally and loc'all\ until tlu* womul 
is completely healed v\'itb or wit I out skin 
grafting. 

Merciiiiiil Diagnosis. C'hronit iindtanim 
ing burrowing ulcer has nlitai bt'cn cun (used 
with other t\j)es of ulceration and (wen with 
jirogressive bacterial s\nergistii' g.inprcius Dos 
trovsky and Sagher, lor example, in [lua’i report 
on “ulcus ])hagedcnic‘uin cutis, " ha\i‘ undonlu 
cdly included both of ihesi* conditions. I low 
ever, they may be clearK differcnliaicd both b\ 
their clinictil course tmd l)\ eareli!l anaeiohic 
bactcrioiogie studies. 4 Ik‘ hemoU nc micro 
acrophilic streptoeoeciis, wbich causes tlu* 
undermining burrowing ulcer, adaj)ls itself 
fairly rajiidly to aerobic emulitions and will 
often grow ecjually well aernbicalh after ihuc 
or four transphinltitions on artilicial media, 
whereas the nonhemolytic nucroacrophilii’ 
streptococcus, which together with the Micro 
coccus pyogenes var. uurnis is ih(* essential 
cause of progressive baeteria! s\ niTvJstii imnyt 
rene, will often remain mieroaeiuphilii’ throucT 
ten or twelve artilicial media l ransplautat ions 
before it adapts itself to (he ataobic tauiron 
ment. 

INrECTlOUS GANCAWNV, OV Tiff SK1\ AM) 
SUBCin'ANIiOl fSDSSUI’.S 

Clangrcne of the skin and subcutaneous tis 
sues, due to microorganisms, may bi‘ i-ither 
acute Ol chionic. 1 he treatment of the ^arimis 
diflcis maikedly, tmcl a delax in dtait 
nosis results in a delay in in.stitiuing the {Proper 
treatment. In the acute cases a diagnosis siioidd 
be made within a few liours, but in tlu* elironie 
ciuses a diagnosis may be safely mack- within a 
few days. Ihc diagno.sis in aciile gangreni* 
must frequently be made largely cm die IxMs 
of clinical .symptoms, but it may !)e promptk 
confirmed oi altered by the immedialt* study of 
stained smears of exudate. In tlic^ chronic fo'rms 
the clinical diagnosis must be fortifiiHl 1>\ tatrm 
ful bactcrioiogie studies. 



79 


Chemotherapy and Antibiotic Therapy of Surgical Infections 


ACQTE GANGP.ENJE 

Acute infectious gangrene may tc divided 
into two subgroups of great importance. These 
differ in so many features that they should not 
be confused. The Erst is relatively common, 
namely, gas gangrene. The second is relatively 
rare, namely, hemolytic streptococcus gangrene. 

Gas GaiigfCEe. Gas gangrene not inf re- 
el uently develops in a deep, punctured or 
lacerated wound which extends down into the 
muscle and carries with it such foreign bodies 
as clothing, missiles, powder or street dirt. It is 
therefore common in war wounds, A large pro- 
portion of the cases of gas gangrene in civil 
practice follow compound fractures. Occasion- 
ally it develops after the amputation of gang- 
renous lower extremities of a diabetic or arterio- 
sclerotic patient. 

Syniptoius. The disease usually begins with 
an abrupt rise in temperature and pulse rate. 
There is general malaise, marked prostration 
and restlessness as well as apprehension. The 
pulse rate approaches 120 and the temperature 
103° to 105° F. There Is usually an increase of 
pain in the wmund. 

Signs. Examination of the wound usually 
reveals swelling and edema, with redness and 
acute tenderness. The skin at the wound mar- 
gin first becomes red, then dusky, then dark 
and necrobiotic, while the reddened area away 
from the margin takes on a yellowish brown or 
bronzed tint. If the disease spreads extensively 
in the muscle, the gangrene of the skin margin 
slowly advances, but it does not appear in iso- 
lated patches away from the margin. Gentle 
pressure on the margins of the w^ound will 
usually produce a sanguinopurulent exudate in 
which gas bubbles may be seen. A smear made 
from this exudate will almost invariably reveal 
numerous, large gram-positive bacilli. Gentle 
palpation of the tissues may reveal crepitus. 
This may not be appreciated in the early stages, 
but after it appears it may advance appreciably 
from hour to hour. An x-ray film will frequently 
demonstrate gas in the tissues even before it 
can be felt. It may also be heard with a stetho- 
scope. To an experienced observer with a 
keenly discriminating sense of smell, there is 
a characteristic acrid or ^ mousy'^ odor. 

Pathology. The spread of the disease is 
chiefly in the muscles. It may he confined to a 
single muscle, extending from the wound mar- 
gin up to its origin, leaving the neighboring 
muscles free, hut usually it spreads up the 


neighboring groups as well, to a varying extent. 
The muscles become soft, mushy and dark red, 
and microscopic sections show fragmentation 
of the muscle fibers with gas bubbles, large 
numbers of gram-positive bacilli and a paucity 
of fixed tissue or wandering cells. 

MacLennan and others have made a distinc- 
tion between the superficial and deep forms of 
gas gangrene depending upon whether the in- 
fection is in the subcutaneous tissues or in the 
muscles. The former they call "anaerobic cellu- 
litis" and the latter "anaerobic myositis." It is 
true that anaerobic cellulitis is less devastating 
than anaerobic myositis because the organisms 
are growing in blood clot or damaged cellular 
tissue and fat rather than in muscle. Thus, the 
spread is less rapid and the toxin less potent. 
In fact, gas infections produced by anaerobic 
streptococci and coliform organisms are prob- 
ably often included in the classification of 
"anaerobic cellulitis." Flow'ever, it is the author's 
opinion that this distinction should not be too 
closely drawn and that any gas-producing in- 
fection should he considered to be gas gangrene 
and surgically explored early and radically if 
the exudate gives presumptive evidence on 
stained smear that large gram-positive rods are 
responsible for the lesion. 

Etiology, There are four diflrerent species 
of spore-forming anaerobic bacilli of the gas 
gangrene group which are pathogenic for man, 
and although they rarely occur in pure culture 
in gangrenous processes, they are believed to be 
able, alone, to produce the general and local 
symptoms of gas gangrene, and their specific 
toxins may cause death. The most common of 
the gas gangrene organisms is Clostridium yier- 
fringens (Bacillus aerogenes capsulatiis'). The 
others are Cl, uovyi (B. oedematiens') , Vibrion 
sepique (Cl. oedematis maligni or Cl, septi- 
cuiii) and B. sordelli (Cl, sordellii or Cl. oedem- 
atoidesf. 

Occasionally one sees an emphysematous in- 
fection in which none of the pathogenic spore- 
forming bacilli are found. In such cases, smears 
of the exudate show only cocci and gram-nega- 
tive bacilli. Cultures yield anaerobic strepto- 
cocci and either aerobic or anaerobic gram- 
negative bacilli. These infections generally 
spread much more slowly than do those that are 
due to gram-positive bacilli. 

Treatment. If the signs are unmistakable or 
if, in doubtful cases, large gram-positive bacilli 
are numerous in the smear, immediate opera- 
tive intervention is of the utmost importance. 



79 


Chemotherapy and Antibiotic 

ACUTE GANGRENE 

Acute iiiFcctious gangrene may be dixided 
into two subgroups of great importance. These 
differ in so many features that they should not 
be confused. The first is relati\'ely common, 
namely, gas gangrene. The second is relatively 
rare, namely, hemolytic streptococcus gangrene. 

Gas Gangrene. Gas gangrene not infre- 
quently develops in a deep, punctured or 
lacerated wound which extends down into the 
muscle and carries with it such foreign bodies 
as clothing, missiles, powder or street dirt. It is 
therefore common in war wounds. A large pro- 
portion of the cases of gas gangrene in civil 
practice follow compound fractures. Occasion- 
ally it develops after the amputation of gang- 
renous lowTr extremities of a diabetic or arterio- 
sclerotic patient. 

Syuiptoins. The disease usually begins with 
an abrupt rise in temperature and pulse rate. 
There is general malaise, marked prostration 
and restlessness as well as apprehension. The 
pulse rate approaches 120 and the temperature 
1037 to .105° R.There'is usually an increase of 
pain in the wound. 

Signs. Examination of the wound usually 
reveals sw'elling and edema, with redness and 
acute tenderness. The skin at the wound mar- 
gin first becomes red, then dusky, then dark 
and nccrobiotic, while the reddened area away 
from the margin takes on a yellowish brown or 
bronzed tint. If the disease spreads extensively 
in the muscle, the gangrene of the skin margin 
slowly advances, but it does not appear in iso- 
lated patches away from the margin. Gentle 
pressure on the margins of the wound will 
usually produce a sanguinopurulent exudate in 
which gas bubbles may be seen. A smear made 
from this exudate will almost invariably reveal 
numerous, large gram-positive bacilli. Gentle 
palpation of the tissues may reveal crepitus. 
This may not be appreciated in the early stages, 
hut after it appears it may advance appreciably 
from hour to hour. An x-ray film will frequently 
demonstrate gas in the tissues even before it 
can be felt. It may also be heard with a stetho- 
scope. To an experienced observer with a 
keenly discriminating sense of smell, there is 
a characteristic acrid or ‘ mousy ^ odor. 

Pathology. The spread of the disease is 
chiefly in the muscles. It may be confined to a 
single muscle, extending from the wound mar- 
gin up to its origin, leaving the neighboring 
muscles free, but usually it spreads up the 


Therapy of Surgical Infections 

neighboring groups as well, to a varying extent. 
The muscles become soft, mushy and dark red, 
and microscopic sections show fragmentation 
of the muscle fibers wuth gas bubbles, large 
numbers of gram-positive bacilli and a paucity 
of fixed tissue or wandering cells. 

iXIacLennan and others ha\'e made a distinc- 
tion between the superficial and deep forms of 
gas gangrene depending upon whether the in- 
fection is in the subcutaneous tissues or in the 
muscles. The former they call “anaerobic cellu- 
litis" and the latter “anaerobic myositis." It is 
true that anaerobic cellulitis is less devastating 
than anaerobic myositis because the organisms 
are growing in blood clot or damaged cellular 
tissue and fat rather than in muscle. Thus, the 
spread is less rapid and the toxin less potent. 
In fact, gas infections produced by anaerobic 
streptococci and coliform organisms are prob- 
ably often included in the classification of 
“anaerobic cellulitis.^’ However, it is the author’s 
opinion that this distinction should not be too 
closely drawn and that any gas-producing in- 
fection should be considered to be gas gangrene 
and surgically explored early and radically if 
the exudate gives presumptive evidence on 
stained smear that large gram-positive rods are 
responsible for the lesion. 

Etiology. There are four different species 
of spore-forming anaerobic bacilli of the gas 
gangrene group wTich are pathogenic for man, 
and although they rarely occur in pure culture 
in gangrenous processes, they are believed to be 
able, alone, to produce the general and local 
symptoms of gas gangrene, and their specific 
toxins may cause death. The most common of 
the gas gangrene organisms is Clostridmm yer- 
fringens aerogenes capsulatus'). The 

others are Cl. novyi (B. oedematiens'), Vihrion 
septique (^Cl. oedematis vialigni or CL septi- 
cnvi) and B. sordelli (CL sordellii or CL oedem- 
atoides). 

Occasionally one sees an emphysematous in- 
fection in which none of the pathogenic spore- 
forming bacilli are found. In such cases, smears 
of the exudate show only cocci and gram-nega- 
tive bacilli, Gultures yield anaerobic strepto- 
cocci and either aerobic or anaerobic gram- 
negative bacilli. These infections generally 
spread much more slowly than do those that are 
due to gram-positive bacilli. 

Treatment. If the signs are unmistakable or 
if, in doubtful cases, large gram-positive bacilli 
are numerous in the smear, immediate opera- 
tive intervention is of the utmost importance. 



80 Chapters. Surgical Bacteriology Chemotherapy and Antibiotic Therapy 


This procedure should not wait for the cultural 
determination of the organisms. The wound 
should be completely excised, and all foreign 
bodies and necrotic tissue should he removed. 
Individual muscles should be explored and any 
inactive or devitalized muscle tissue removed. 
When all the involved muscle that can safely 
be removed surgically has been excised, the 
wound should be flooded with a creamy sus- 
pension of sterile (Du P ont s medicinal grade) 
zinc peroxide (now distributed only by Mal- 
linckiodt) in sterile distilled water and then 
packed lightly with gauze or absorbent cotton 
soaked in this material. This in turn is covered 
with a thick layer of cotton soaked in distilled 
water. The whole dressing is sealed with petro- 
latum gauze to prevent evaporation. This dress- 
ing should be changed daily until the anaerobic 
organisms have disappeared from the wound. It 
has been demonstrated that zinc peroxide not 
only quickly kills the anaerobic organisms with 
which it comes in contact but neutralizes the 
Welch bacillus toxin. However, its action is only 
on the wound surface. If the disease is diag- 
nosed soon after its development, amputation 
usually is not indicated unless there is a com- 
pound fracture. Gas gangrene antiserum should 
be used in large quantities. Depending on the 
severity and extent of the infection, two or 
more “therapeutic doses” should be given intra- 
venously as soon as the diagnosis is made and 
repeated every eight hours until there is defi- 
nite subsidence of local and general symptoms. 
If it is not possible to determine by culture 
what organisms are present, a polyvalent serum 
should he used, but if an analysis of the flora of 
the wound has been made, more specific anti- 
serum should be administered in subsequent 
treatments. 

A number of favorable results have been 
reported from the use of roentgen therapy. It 
is thought that the rays produce peroxides in 
the tissues. One hundred roentgens to the af- 
fected areas twice a day for three days is the 
advocated dose of x-rays. This form of treat- 
ment has not been approved generally. The 
sulfonamides are of doubtful value in the 
treatment of this disease. In World War II 
penicillin was used with encouraging results, 
but with many disappointments, because, al- 
though the gas gangrene organisms are sus- 
ceptible to penicillin, the drug is often inacti- 
vated by the associated organisms which pro- 
duce penicillinase. These are chiefly the aero- 
bic gram-negative rods of fecal origin which 


are almost invariably found in cases oi gas gang 
rene in association with Cl perjririocjis. i heir 
effect may be overcome to a degree by increas 
ing the dosage of penicillin to a million or even 
ten million units a day. However, even these 
large doses will not be cftccti\x‘ unless the 
"toxin factory” (which is the involved necrotic 
muscle) has been surgically remewed. Pvcsidiial 
cellulitis may then be controlled by the coiiv 
billed use of antitoxin and penicillin. Pacilracin 
is also effective against the gas gangrene group 
of organisms. It is not inhibited b>' the peni 
ciliinase producers and may be used s\'stem 
ically in the treatment of gas gangrene. Cddor 
aniphenicol and chlortetracycline have also 
demonstrated their value in experimental gas 
gangrene in animals and warrant clinical trial. 

Hemolytic Streptococcus Gangrene. Since 
the authors first report, in 1924, this inlection 
has been described by several observers. 1 his 
disease may occur following a deep w'ouncl hut 
is more likely to follow a much more trivial 
injury, such as a scratch, a cut or a hypodermic 
injection. It generally occurs on the ext re mi 
ties but may involve any part of the body. In 
the earlier literature some of these cases wort* 
described as phlegmonous or gangrenous cry 
sipelas, but there are striking difrcrences be- 
tween the disease and erysi])elas, which will 
be brought out later. 

Symptoms. The disease is charactcri/txl h)* 
the sudden onset of pain and swelling at tlie 
site of the injury. The temperature generally 
does not rise to over lOD or 102^ 1%, exee[)t in 
rare instances when the illness is ushered in 
with a chill. Then the temperature may reach 
103° or 104° F. On the other hand, ihe pulse 
rate is rapid, frequently approaching 120. Pros 
tration is marked, but instead of irritability, 
there is usually marked lassitude. \Hie patient 
becomes indifferent to his surroundings and 
has no appreciation of the severity of his ill- 
ness in direct contrast to the great apprehen- 
sion shown by the patient with gas gangrene. 

Signs. Within twenty-four hours the part 
becomes red, hot, swollen and heavy, and 
while at first it may be extremely painful, it 
later becomes numb or anesthetic. The redness 
spreads rapidly during the first two days and 
may be very marked, but the margins fade out 
into the normal skin and are not raised as in 
erysipelas. On the second, third or fourth clay 
the pathognomonic sign of the disease appears. 
This should be watched for in any acute fith 
minating inflammation. The sign is a dusky 



Chemotherapy and Antibiotic Therapy of Surgical Infections 81 


coloring of the shin, appearing in a small pur- 
plish patch with irregular and ill-defined mar- 
gins. It may be some distance from the portal 
of entry. It has at first a bluish tinge, which 
makes it distinct from the brilliant redness of 
the surrounding skin. At the same time a large 
blister or bulla may appear over this dusky 
area or somewhere else on the red surface. 
These areas may extend rapidly, and changes 
in them may be seen from hour to hour. In un- 
treated patients about the seventh, eighth or 
ninth day, if the patient survives, this necrotic 
skin becomes more sharply demarcated from 
the rest of the skin, and a little later, partial 
separation takes place along the edges. Meta- 
static foci may develop in the lungs or joints 
or elsewhere in the body. Frequent sites for 
these metastatic lesions are the subcutaneous 
tissues, usually without gangrene. In a few 
untreated patients the process may come to a 
standstill about the end of the second week, 
and large plaques of necrotic subcutaneous fat 
may separate beneath a relatively normal skin. 
But as a rule, if no treatment is given, the case 
goes on to rapidly overwhelming toxemia, with 
septicemia, extensive metastases and death. 

Pathology. This disease is essentially a 
gangrene of the subcutaneous tissue with sec- 
ondary gangrene of a part of the overlying skin, 
resulting from thrombosis of the skin arteries 
which pass through the sloughing subcutaneous 
fat. The subcutaneous gangrene may extend 
for a long distance beyond the area of skin 
gangrene but hardly ever extends down into 
the muscle or bone unless the original wound 
carries it to these depths. The blood culture is 
positive in about half of the cases. 

Etiology. The hemolytic streptococcus is 
always found on aerobic culture in these cases, 
and in the great majority of cases it may be 
found in pure culture out in the advancing 
margin of the subcutaneous necrosis as well as 
in the blister or bullar fluid. Beyond the limit 
of the subcutaneous necrosis, there is a zone of 
redness and edema which yields a sterile cul- 
ture. Later, when the gangrene separates, other 
organisms may contaminate the field but usu- 
ally do not spread widely. It is almost certain 
that these associated organisms play no part in 
the development of the disease and that it is, 
in fact, a pure hemolytic streptococcus infec- 
tion. The rapidity of its development and the 
extensive necrosis which it causes suggest that 
the peculiar characteristics of the onset of the 
infection may be due to a hypersensitivity 


similar to the Shwartzman or to the Arthus 
phenomenon. 

Treatment. As soon as the diagnosis has 
been made, penicillin should be given in doses 
\mying from 40,000 to 50,000 units every 
three hours. Surgical treatment should not be 
delayed an hour after the diagnosis has been 
made. If it is delayed for twenty-four hours 
after the pathognomonic signs appear, the 
chances of recovery will be greatly diminished, 
and the extent of the subsequent skin necrosis 
will be greatly increased. Contrary to the usual 
procedure either in erysipelas or in strepto- 
coccus cellulitis of the ordinary kind, longitu- 
dinal incisions should be made at once through 
the gangrenous area and should extend in both 
directions just beyond the limits of the sub- 
cutaneous necrosis. The effect of these incisions 
is to relieve tension and to drain, at least par- 
tially, the involved area. After operation, hot- 
water soaks or hot poultices should be used 
until the cellulitis subsides. This usually re- 
quires two or three days. Then Dakin s fluid 
should be applied by means of tubes or fre- 
quently changed compresses to favor the rapid 
separation of the slough. Each day as much of 
the slough as can be removed without bleeding 
should be cut away. Penicillin, in a dosage of 

50.000 units every three hours, or bacitracin, 

20.000 units every six hours, whichever is more 
potent against the causative organism, should 
be given until the infection has come under 
complete control. Zinc peroxide is not effective 
in this condition, because the extensive slough 
prevents adequate contact. 

Differential Diagnosis. Fulminating types 
of gangrene fall either into the gas gangrene 
group or into the hemolytic streptococcus gang- 
rene group. They should not be confused, for 
in the former the injury is almost always deep, 
and the invasion is largely in the muscular 
layers, with gas formation and crepitation both 
in the muscles and in the subcutaneous tissues 
while the skin is relatively free. In hemolytic 
streptococcus gangrene, on the other hand, the 
injury is usually superficial, and the spread is 
almost always in the subcutaneous tissues, with 
early involvement of the skin and without any 
crepitation. In gas gangrene the general symp- 
toms are alarming and the local signs relatively 
mild. In hemolytic streptococcus gangrene the 
local signs are alarming and the general symp- 
toms relatively mild. While both infections are 
primarily due to specific organisms, infection 
may be rendered more severe by the association 



82 Chapter 3. Surgical Bacteriology, Chemotherapy and Antibiotic Therapy 


TABLE 2. DIFFERENTIATION OF CASES OF ACUTE OANCaiENF, 


NAME 

lilTIOLOGY 

SVMPTOMAI'OI.OOY 

p vniDLorA’ 

! Rl \ I Ml.\ r 

Gas gangrene 

Deep wound into 
muscle. Large gram- 
positive rods pre- 
dominating in 

stained smear of 
exudate. Usually 
Cl. perjringeits on 
culture. 

Occasionally anae- 
robic streptococci 
in association with 
aerobic or anae- 
robic gram-nega- 
tive bacilli. 

Early development 
of various kinds of 
associated bacteria. 

Sudden onset. Pro- 
found gencM-al 

symptoms. High 

fever, rapid pulse, 
apprehension, ir- 
ritability. Relative- 
ly mild local signs. 
Limited redness, 

swelling, and ede- 
ma of skin. Crepi- 
tation. Dusky 

wound margins. 

Bronzing of skin. 
Limited gangrene. 

■ Exten.sive death o 

■ niiiscl(A ImIxt; 

brokem by gas for- 
mation. May spt'ea( 
whok' length of 
.single muscle. IN- 
udat(‘ loaded witli 
gram-positive rods, 
Relatively few pib 
cells. Negative 

chemoUixis for leu- 
kocytes. 

f Pioinpl opei\jtion. Rr- 
iiioval ()| all I'orcign 
l)odi(‘s and (k-ad tis- 
1 sue. ( Iouij)le((‘ df-- 

i- 1 )i’i(k ‘u ir u ( ( )! \s on lu 1. 

- Daily lloodmit 

1 wound with a water 

suspi'iisii )u of Du 
’ Pont uiedicinal 

grade' ziiK' [X'roxidtr 
• I'kirly aclniinistratiou 
of larg(' rpiautities 
ol polyvalent or sjie- 
cifie sei'nin. 

Penicillin in large 
d()s<‘s. 

Bacitracin, (diloram- 
plimiicol or (dilortc- 
tracycliiK'. 

X-rav' tlu'rapv. 

Hemolytic 

streptococcus 

gangrene 

Superficial wound. 

Only chained cocci in 
stained smear of ex- 
udate. 

Pure culture of hem- 
olytic streptococ- 
cus. 

No other bacteria or 
late occurrence of 
a few other species 
after gangrenous 
skin has separated. 

Sudden onset. Rela- 
tively mild general 
symptoms. Low fe- 
ver but rapid pulse. 
Lassitude, indiffer- 
ence, somnolence. 
Alarming local 

signs. Extreme red- 
ness and edema 
without sharp mar- 
gins. Irregular 

dusky areas on sec- 
ond, third or fourth 
day. Blisters and 
bullae. Rapidly de- 
veloping extensive 
gangrene. 

Extensive necrosis of 
subcutaneous tis- 
tucs with a witle 
zone of stei'ile eck'- 
ma beyond the lim- 
its of necrosis. 
Heavy exudation of 
fluid and polyinor- 
phonuch'ars at first 
and later large 
mononuclear phag- 
ocytes. Bacteria 

found all through 
the necrotic subcu- 
taneous fat and in 
the bli.stcr.s and 
bullae. 

Thrombosis of soni(‘ 
blood v(?.s.sels to 
overlying skin, 

which bt'coiru's 

gangrenou.s. 

Prompt operation. 

Long incisions to 
th(‘ limits of tiu' snb- 
cntaiK'oiis necrosis. 
Rek’a.si* of ail (eii- 
>^ioii. K(*ino\‘al oj' 
n<‘ci-otic tissue as 
soon as possifik* 

with a mininiinn ol 
l)k‘eflinL.>. I hit jip. 
plications of moist 
doat until snb.sid- 
ol (’(dlnlitis. 
d'ben Daldifs solu- 
don to favor st'pa- 
ration of the 

■slongli. 

Peni(dllin or bacifra- 
can. 

^^ullhnilamiih' or sul- 
fadiazim*. 

Skin grafting if d<dert 
is extensive. 

Erysipelas 

Superficial or no ap- 
parent wound. 

Pure culture of 
hemolytic strepto- 
coccus. No associ- 
ated bacteria. 

Sudden onset. Pro- 
found general 

symptoms. Chill. 
High fever. Rapid 
pulse. Apprehen- 
sion. Irritability. 
Slowly but steadily 
spreading area of 
redness with little 
or no swelling and 
color fading in the 
center . Sharp 

raised margins. 

Slight .swelling and 
thickening of skin. 
No cdcina of sub- 
cutaneous fat. Bac- 
teria in and bt^yond 
advancing zone and ! 

not in center of 
lesion. 

J 

No operation. .Sooth- 
ing local applica- 
tions. Ultraviolet 

liglit, Smaim in se- 
vere cases. 

Snlfanilamiik- or sul- 
fadiazine, if ultra- 
vioRd radiation i.s 
not usial, 

Ponidllin or badtra- 
cin. 



83 


Chemotherapy and Antibiotic 

oF other bacteria. However, in the case oF gas 
gangrene, these organisms generally gain a 
Foothold at the same time or beFore the organ- 
isms oF the gas gangrene group, whereas with 
hemolytic streptococcus gangrene, the hemoly- 
tic streptococcus is alone responsible for the 
initiation of the inFcction, and seconclarv con- 
taminants grow only after there has been a 
hi oak at the margin of the gangrenous portion 
of the skiji. Stained smears of the exudate in 
show many gram-positive rods, 
while in streptococcus gangrene the exudate 
contains only gram-positi\'e diplococci or short 
chains. 

F Icmolytic streptococcus gangrene has been 
frequently confused with erysipelas, which is 
likewise caused by a hemolytic streptococcus, 
but certain features sharply distinguish them. 
They may be differentiated by reference to 
Table 2. 

CHRONIC GANGRENE 

Cases of chronic infectious gangrene may 
be separated into four important subdivisions. 
While all of these groups are characterized by 
some distinctive clinical features, it seems cer- 
tain that in each type the characteristic lesions 
arc produced not by one organism as in the 
acute cases but by a special combination of two 
or more organisms. These diseases may there- 
fore be called synergistic infections. They may 
be conveniently named as follows: (1) post- 
Oj:)erative progressive bacterial synergistic gang- 
rene of the abdominal or chest wall, (2) gang- 
renous impetigo (ecthyma), (3) fusospiro- 
chetal infection of the skin and (4) amebic 
infection of the skin. 

Postoperative Progressive Bacterial Syner- 
gistic Gangrene. One of the most striking 
examples of chronic gangrene of the skin is that 
which occasionally follows the drainage of an 
abscess either in the peritoneal cavity or in the 
chest. Cullen was the first to describe this con- 
dition in 1924. Brewer and the author subse- 
quently reported cases with laboratory studies 
demonstrating the synergistic bacterial origin 
of this disease. This has been repeatedly con- 
firmed. This disease has been observed in 
widely scattered geographical areas. 

Sympiofiis'. In the majority of the cases 
which have been reported, the gangrene has 
followed drainage of a peritoneal abscess. Usu- 
ally there is little general reaction manifested 
either by fever or anemia, and the patient re- 


Therapy of Surgical Infections 

mains in fairly good general condition, al- 
though as the process goes on, he is gradually 
worn down with discouragement and pain. 
About the end of the first or second week after 
operation, the patient and the doctor both 
realize that all is not w^ell with the healing of 
the wound. The whole region becomes ex- 
quisitely tender. This symptom is an outstand- 
ing feature of the disease. At first the wound 
becomes red, swollen and tender. In a few days 
the wound margins or the stitch holes develop 
a carbuncular, indurated, necrobiotic appear- 
ance. The center of activity becomes purplish, 
while the outer zone takes on a brilliant red. 
Within a few days, the purplish areas widen, 
and the part first affected becomes frankly 
gangrenous. The color of the dead skin changes 
to a dirty grayish brown, and the surface is 
dull like suede leather. The purple zone spreads 
outward into the red, and as it does so the skin 
becomes raised above the normal skin level. 
The central side of the purple zone, toward 
the gangrene, is sharply defined but irregular 
and crenated. On the outer side it fades off 
into the red zone and flattens to the level of the 
normal skin. The gangrenous skin remains 
firmly adherent to the purple zone and becomes 
undermined at its free margin, but there is 
little if any undermining of the normal skin. 
As the process advances, the gangrenous skin 
liquefies on its inner margin, leaving exposed 
a base of granulations which gradually en- 
larges. 

Pathology. The lesion is essentially a ne- 
crosis of the skin. The destruction of the dermis 
is not aWays complete, and here and there 
some deep islands of epithelium, from sweat 
glands or hair follicles, may start patches of 
regenerating skin. In the gangrenous zone, all 
of the tissues are homogeneously necrotic, and 
masses of cocci in clusters and chains may be 
found. In the purple zone there is edema and 
a dense infiltration with wandering cells. Here 
fewer organisms are present, and they appear 
in diplo form and in short chains. In the red 
zone there is hyperemia and a few diplococci. 

Etiology. In most of the cases reported in 
the literature, only routine bacteriologic studies 
were made, but when careful anaerobic as well 
as aerobic methods are used a microaerophiUc 
nonhemolytic streptococcus may be found in 
pure culture at the periphery of the lesion, not 
only in the red zone but occasionally just be- 
yond it in the relatively normal tissues. In the 
gangrenous tissue itself, this organism is found 



84 Chapter 3. Surgical Bacteriology, Chemotherapy and Antibiotic Therapy 



Figure 5. Typical progressive bacterial synergistic gangrene following cecostoms'. Note the two 
starting around retention sutoes. Firmly adherent, suede leather gangrene surrounded hr' raised purple 
with crenated inner margin. Bright red zone on outside fading oil' into normal shin. • ' ' > 


areas 


/.one 


to be associated with a hemolytic Micrococcus 
pyogenes var. aureus. When the streptococcus 
or micrococcus is injected in pure culture into 
animals, no lesion is produced, but when half 
doses of each organism are combined and 
injected, a gangrenous process usually develops 
which will spread during the course of three 
or four days and simulate to a considerable 
degree the lesion in man. This has been re- 
Fatedly confirmed. With the demonstration 
that these organisms can do something together 
which they cannot do alone, the theory has 
been advanced that the disease is the result of 
a synergistic action of the two organisms, the 
nonhemolytic microaerophilic streptococcus 
eing the essential organism in the zone of 
advance and in some way preparing the ground 
or t e gangrenous action of the micrococcus. 
Ihe streptococcus is almost certainly derived 
from the intestinal tract, while the micrococcus 

may come from the patient’s skin or from the 
air» 

r'reatrmnt. In most of the reported cases 
the original wound was partially closed with 
tension sutures. Such tissue tension in the 

fwTkv favored 

the establishment of the infection. This sug- 
gests K a prophylactic measure that all skin 
wounds should he left unsutured when a 

abL°srfs or lung 

bscess IS drained. The chronicity of this con- 


to CLiie it by many methods. Clcrtain of the 
reports reflect the ingenuity and persistence of 
surgeons in usiing all sorts of chemical and 
serologic agents both generally and locally in 
the face of a ballling problem. In almosi every 
case, conservative nictliocls, including local ex- 
cision of the gangrenous nuirgiiis, have failed 
to check the advance of this process, hut radi- 
cal removal of the lesion, including the outer 
zone of redness, either with the knife or with 
the cautery, has almost invariably resulted in 
prompt disappearance of the clisea.se. Sterilized 
medicinal grade zinc jicroxiclc suspended in 
distilled water and applied after the e.vcisitm 
helps prevent a mcurrencc of the infection. 
Under its application granulations soon appear, 
the defect left by this radical operation mav 
toen very quickly be restored by skin .grafting, 
the author has treated two patients svstemi 
cally with penicillin, with prompt and eoin- 
piete subsidence of the inflammation, spon- 
taneous separation of the gangrenous margin 
and progressive healing without the noeessitv 

a third patien't 
tailed to res]^nd to penicillin because of the 

penicillinase in the wound hv 
one of the secondary contaminants. Five oilier 
pahents have since been treated both locallv 

ontrol of the infection within seventy-two 
hours, spontaneous separation of the slough 
and regeneration of the surface epithelium, thus 


85 


Chemotherapy and Antibiotic 

completely obviating the nccessiU' tor surgical 
extirpation. Marcus has reported one severe 
case which responded to chloramphenicol. 

GangreEous Impetigo (Ecthyma). For a 
good many years reports ha\'e appeared in the 
literature describing a chronic gangrenous 
disease of the skin appearing in undernour- 
ished persons, both young and old, who were 
generally in a low state of nutrition and were 
frequently suffering from recurrent attacks of 
dysentery. It has been given many names by 
dermatologists, among them, ecthyma, pyo- 
derma gangraenosum, impetigo gangraenosa 
and dermatitis gangraenosa. 

Syviptoms. There are very few symptoms 
with the onset of the infection. Crops of 
vesicles appear which soon become pustulous 
and then frankly gangrenous. As they progress, 
they become moderately or seriously painful, 
and the patient is conscious of fever and ma- 
laise. This condition may last for months or 
years with exacerbations and remissions. Fre- 
quently a crop of small, fresh gangrenous le- 
sions may develop after a recurrence of diarrhea 
or colitis. 

Signs. The lesions are usually multiple and 
show various stages of development, one lesion 
following another in rather rapid succession. 
They occur most frequently on the scalp, face 
and abdomen hut may be found on any part of 
the body. They generally start as small vesicles 
surrounded by a red zone. The center then be- 
comes dark, gangrenous and depressed. The 
lesion increases in size slightly, and occasion- 
ally two or three neighboring lesions coalesce, 
but even the coalesced lesions seldom measure 
more than 1 or 2 cm. in diameter. The disease 
is contagious and frequently occurs in several 
members of a family at the same time. Like- 
wise, the patient inoculates other areas of his 
body. As new lesions develop, the old ones fre- 
quently dry, the necrotic skin comes off as a 
scab and a scar is left behind. The larger and 
deeper lesions, however, may persist for a long 
time. The gangrenous center then separates at 
the margin, leaving a ring of depressed ulcera- 
tion from the center of which the gangrenous 
plaque stands up like a button. If this sepa- 
rates from its base, a clean ulcer is left wdiich 
slowly heals. 

Pathology. The necrosis is relatively super- 
hcial, with a base of granulations infiltrated 
with wandering cells, chiefly of the large mono- 
nuclear variety and with gram-positive cocci in 
short chains and masses. 


Therapy of Surgical Infections 

Etiology. The cause of this disease has been 
\nriousl\' explained b\' different authors, but 
several works ha\u regularly found a hemo- 
lytic streptococcus and a staphylococcus in the 
lesions and have attributed the disease to a 
synergistic action of these organisms. With 
these two organisms in combination, similar 
lesions have been produced in animals, while 
pure cultures of either failed to do so. 

Treatment. Most authors believe that the 
majority of these patients will recover if general 
nutritional measures are instituted and if the 
usual methods of treating impetigo are con- 
tinued industriously. Many cases have re- 
sponded to ammoniated mercury, but some 
have resisted all forms of treatment except com- 
plete excision of the individual lesions. Penicil- 
lin and bacitracin should be used together in 
this disease for their synergistic action. 

Fusospirochetal Infection of the Skin. A 
third type of chronic gangrene is represented 
by the foul infections developing in wounds 
made by human bites or in wounds wTich 
have been contaminated by secretions from 
the mouth. This condition is well described by 
Flick. Usually gangrene does not develop in 
these cases unless there is a mixture of or- 
ganisms which includes nonhemolytic strepto- 
cocci, fusiform bacilli and spirochetes. Although 
spirochetes are never found alone in these in- 
fections, the worst cases are certainly those in 
which spirochetes are present. The infection 
almost always occurs when a human being 
either voluntarily bites another or strikes a 
blow with his hand and is cut by the teeth of 
the intended victim. The wound is usually a 
lacerated wound of considerable depth, but 
cases have been reported in which the injury 
was superficial. It is surprising that more 
wicked infections do not develop in wounds 
that have been sucked, for this is a common 
practice. It is probable that organisms are not 
planted in the depths by this procedure. 

Symptoms. There is usually some evidence 
of inflammation around the bite within the 
first two or three days after injury, and this 
steadily progresses. The part becomes swollen, 
painful and useless. Fever is usually moderate 
hut may he high. Ordinarily the systemic reac- 
tion is not profound, but the local condition 
soon becomes alarming. 

Signs. The affected part very quickly be- 
comes markedly swollen, with unusually hard 
induration. The exudate becomes foul; and the 
margins of the wound arc shaggy, bleed easily 



86 Chapter j\ Surgical Bacteriology, Chemotherapy and Antibiotic Therapy 


and take on a dark gra}'-grecn appearance. The 
infection may spread fairly rapidly into the 
neighboring bones and joints. It barrows down 
into the deep spaces and may work up again 
toward the surface and break out at some dis- 
tance from the original u^ound. Thus, multiple 
sinuses are produeed, or, if incisions are made 
in various places, the wounds remain open and 
continue to discharge the foul-smelling exudate. 
Unless the proper treatment is instituted, these 
infections go on steadily for weeks or months 
with progressive destruction, not only of the 
skin and subcutaneous tissue but of the deeper 
structures. 

Pathology. There is marked edema of the 
tissues and a dense infiltration with wander- 
ing cells. There is extensive necrosis of tisstte. 
With the proper staining methods, spirochetes 
and spirilla as well as fusiform bacilli may 
be demonstrated. 

Etiology. If smears are made from the foul 
exudate, countless organisms are seen, among 
them streptococci, fusiform bacilli and spiro- 
chetes-the latter are better seen with the dark- 
field illumination. These organisms will de- 
velop only under anaerobic conditions and are 
grown best in or on special media. A great 
many serious human bites occur in which only 
streptococci and staphylococci are found, but 
usually in these cases, although infection is se- 
vere and the general symptoms are marked, 
there is no gangrene of the tissues. Although 
hemolytic streptococcus gangrene might de- 
velop after a human bite, I have not ob- 
served such a case. If gangrene is present, 
either the fusiform bacilli or the spirochetes 
are usually to be found, and in the severer 
cases the patients harbor both of these or- 
ganisms. 

Treatment. Bates, who had considerable ex- 
perience with infections of this kind, advised 
treatment of wounds caused by human teeth 
by radical excision with the electrocautery as 
soon as the patient was seen. This, he believed, 
is an important prophylactic measure. When 
the infection has already gained a foothold, 
most authors have found that any temporizing 
measure is unsuccessful, and they advocate 
complete debridement of the involved tissue, 
which may mean amputation of a finger or 
hand. The presence of spirochetes has sug- 
gested the treatment of these infections with 
sprocheticidal chemical substances; and al- 
though arsphenamine has frequently been used 
without much success, better results have been 


obtained with neoarspbcnaminc. Penicillin is 
often cfi'ective in controlling these inicclions if 
given early, and in many cases the organisms 
are susceptible to bacitracin, ixnan and hong 
acre have reported good results with bacitracin 
and conservative surgery. P)cforc these anti 
biotics were available, it was found that 
the most cflectiv'c treatment, either as a pro 
phylactic measure or alter debridement in an 
established inlcction, consisted in the use of 
Mallinckrodt medicinal grade zine peroxide. 
This is still a clepcndalilc method of treatment 
if the antibiotics (ail to bring the infection 
under control within seventy-two hours. 1'hc 
zinc j:)eroxidc must be applied to the wound 
and sinuses as a thick, creamy sus[X'nsi()n in 
distilled water. The wound should then he 
]>acked with hne-mesh gauze or absorbent cot 
ton soaked in the zinc peroxide siisjxmsion, 
covered with a thick layer of cotton wot vvilh 
distilled water and then scaled with petrolatum 
impregnated gauze to prevent evaporation, d'his 
dressing should be changed daily until the in 
fccting organisms have completely disappc'art‘cl. 

Amebic Gangrene. Amebic infection of 
the skin has been described by a nuniher of 
authors practicing in regions in which amebic 
disease is common. In most of the cases which 
have been reported, the invok'cmcnt of die 
skin has been secondary to spontaneous or o[) 
erative drainage of a hepatic abscess. A lew 
cases of infection of the skin luu'c followtnl 
some operative procedure on tlie large* intes 
tine. Fistulae about the anus clue to amehae 
have been described. Gangrenous lesions oi‘ the 
skin attributed to araebae, which seemed to 
arise without any direct connection with tin 
internal focus of the disease, have also licea re 
ported. A lesion of the buttock and scrotum 
has been described which was clearly differen 
dated from progressive bactcriologic synergistic 
gangrene by careful bactcriologic and pathidogie 
studies. 

Symptoms. In the cases in which ti gtm 
gienous lesion of the skin develops sc^’ondtiry 
to the drainage of a deeper focus, there is al 
ways a period of days or weeks during wliich 

there is no specific change in the wound. 
Then the drainage tract becomes red, swollen 
and painful in a manner similar to that in 
many drained wounds. Fever is not a promi- 
nent feature in these cases. 

Signs. The edges of the wounds become 
indurated, everted and raised above tlic sur- 
rounding skin, which takes on a dark brown 



87 


Chemotherapy and Antibiotic 

color with hyperpigmentation. As the necrosis 
spreads, the center of the lesion remains as an 
ulcerated surface covered with dark granula- 
tions having “a color resembling that of raw 
beet which has been exposed to the air for 
some time” (fleimburger). The surface is cov- 
ered with foul-smelling exudate of thick, brown- 
ish, blood-tinged pus with shreds of necrotic 
tissue in it. 

Pathology. Usually the chief involvement 
is ill the skin and subcutaneous tissue, but the 
muscle may be involved, in which case the 
whole wound becomes necrotic for a consider- 
able depth. In amebic lesions which have no 
connection with a deep focus, the infection 
with amebac apparently must be preceded bv an 
established infection with other organisms. This 
at once suggests the possibility of a symbiotic 
rather than a specific action. In such a case the 
infection remains relatively superficial. The 
spread seems to be in the cutis, while the epi- 
dermis is involved secondarily and gives way. . 
Glairy pus in small droplets may be expressed 
from the margin of the ulceration. This is said 
to be quite characteristic of the infection. 
Amebae may be found in the advancing zone 
of gangrene. 

Etiology, In only one of all the case reports 
reviewed by the writer have careful anaerobic 
as well as aerobic bacteriologic studies been 
mentioned. The bacterial factor either alone or 
in symbiosis with the amebae may not have 
been given the attention which it deserves, 
but in the authors case such studies were 
made, and the conclusion was drawn that ame- 
bae may be the essential factor in the produc- 
tion of this type of lesion. It seems to the 
writer that one or all of the following condi- 
tions should obtain before it can be fairly stated 
that amebae are participating actively in any in- 
fection : ( 1 ) there should be histologic evidence 
of the invasion of the tissues by the amebae, 
(2) they should be found either by smear or 
culture in the advancing margin of the lesion, 
or (3) the lesion should respond to medical 
treatment recognized as adequate for amebic 
disease. The writer believes that the mere 
presence of amebae on the surface of the lesion 
or in the exudate is no more evidence of their 
participation in the infection than the pres- 
ence of Esch. coli, P. vulgaris, Cl. perfringens 
or any of the other intestinal organisms is evi- 
dence of their activity in the tissues about a 
fecal fistula. 

Treatment. In all cases uf amebic abscess 


Therapy of Surgical Infections 

of the liver, the possibility of skin necrosis 
after drainage must he kept in mind and pre- 
cautions taken to a\'oid it. An attempt should 
be made to protect the skin wound at the time 
of operation. A two stage procedure might in- 
crease wound resistance to the infection. If a 
one stage operation is performed, there should 
be complete relaxation of the wound, with no 
attempt to close the skin and subcutaneous tis- 
sues by suture. If pathogenic amebae have 
been found, bacitracin should be given orally 
and intramuscularly and applied locally in oint- 
ment or in solution. If this fails, emetine hy- 
drochloride should be given intra\'enously and 
Ana\odm by mouth. Oral oxytetracvcline is 
also effective in ridding the intestinal tract of 
amebae. 

Differential Diagnosis. The differentiation 
between the groups of chronic infectious gan- 
grene is difficult, particularly between the bac- 
terial synergistic and the amebic groups, both 
of which usually follow an operative procedure. 
In the bacterial synergistic group there is no 
history of amebic infection or evidence of a deep 
amebic lesion, no amebae are found either in 
the stools or in the exudate from the lesion 
or in the tissues, and there is no response to an- 
tiamebic treatment. In the amebic cases there 
is frequently a history of previous amebic dys- 
entery or a frank deep amebic lesion. Amebae 
are frequently found in the stools as well as 
in the exudate from the wound and in the tis- 
sues, and the lesions may respond promptly, 
often surprisingly, to emetine and Anayodin 
treatment. In bacterial synergistic gangrene, 
the lesion is extensive but superficial and 
develops slowly. It does not invade the muscle, 
and the base of the ulcerated center is com- 
posed of active granulations which frequently 
reveal isolated islands of regenerating epi- 
thelium. In the amebic infections the lesion is 
usually deeper, it develops more rapidly and 
it may involve the muscle. The granulations 
have a raw beef appearance, and islands of re- 
generating epithelium are rare. Pressure on the 
margins produces glairy pus in which the 
amebae may be found. All the lesions of pro- 
gressive bacterial synergistic gangrene which 
have been cultured both aerobically and an- 
aerobically at the time of excision have yielded 
a microaerophilic nonhemolytic streptococcus 
in pure culture in the spreading periphery of 
the lesion, while cultures in the zone of gan- 
grene have revealed this organism in associa- 
tion with others. As far as the writer is aware, 



88 Chapter 3. Surgical Bacteriology, Chemotherapy and Antibiotic Thcraj 


TABLE 3. DIFFERENTIATION OF CASES OF CHRONIC: CIANCRKNE 


NAME 

ETIOLOGY 

SYMPTOMAl'OLOG\' 

PATiior 0(n' 

TKI-'.ATMI'.N 1 

Postoperative 

progressive 

bacterial 

synergistic 

gangrene 

Essential organism: 
Microaerophilic 
nonhemolytic strep- 
tococcus {Str. evolu- 
tus), in the spread- 
ing periphery of 
the lesion, associ- 
ated with staphylo- 
coccus (M. pyogenes 
var. aureus) in the 
zone of gangrene. 

Usually follows 

drainage of perit- 
oneal abscess, lung 
abscess or chronic 
empyema. Wound 
margins or reten- 
tion suture holes 
after one or two 
weeks take on a 
carbuncular ap- 
pearance finally 

diflerentiating into 
three skin zones, 
outer bright red, 
middle dusky pur- 
ple, and inner gan- 
grenous with a cen- 
tral area of granu- 
lation tissue. 

Excruciating pain. 

UeshTicdon of epidcr- 
iiiis and upper lav- 
ers of dermis fre- 
quently leavinu 

some dt'i'p reninunts 
ol epithelium vvhi('!i 
later regeneral e. 

Under gangnaie, 

heavy polymorpho- 
nuclear exudation. 
Under purple zone*, 
hemorrhage. Uiichu' 
red zone, hyp('r- 
etnia. Many staph- 
ylococci and strep- 
tococci under gan- 
grene. Scattered 

streptococci in tlu' 
periphery. 

CO IS — 

Gangrenous 

impetigo 

(ecthyma) 

Essential organisms: 
Hemolytic strepto- 
coccus and hemoly- 
tic staphylococcus 
{M. pyogenes var. 
aureus ) . 

Usually occurs in de- 
bilitated persons, 
especially those 

suffering from 

chronic dysentery. 

Lesions are usually 
multiple and may 
coalesce, but are 
seldom large. 

Start as vesicles going 
on rapidly to pustu- 
lation and gan- 
grene. 

Usually superficial 
destruction of ti.s- 
suc with drying of 
the gangrenejus 

skin, scab forma- 
tion, and separa- 
tion, Moclerat<‘ 

polymorphonu- 
clear exudation. 

Local invasion of 
staphylococci and 
streptococci. 

R<‘ni()val of crusts. In 
temsiv'e i<)<’al appli 
caiion ol ammoiii 
at<‘cl merrury oinl 
inent. General nu 
tritional trealment. 

Sulfanilamide or sul 
fadiazim*. 

IVnieillin or f)a(:itra 
ciri <n' both. 

Fusospirochetal 

gangrene 

Essential organisms: 
Fusiform bacilli, 
spirilla, and spi- 
rochetes usually 

associated with 

nonhemolytic 
streptococci (aero- 
bic or anaerobic). 

Usually occurs in a 
wound contami- 
nated with mouth 
secretions, e.g., hu- 
man bite. Early in- 
flammation with a 
gradual develop- 
ment of necrosis of 
wound edges with 
penetration to bones 
and joints. 

Extensive slougiiing 
of supcrficiai and 
deep tissue with 
multiple sinu.s for- 
mation. Organisms 
profuse in exudate 
and in the necrotic 
tis.sucs. 

Penicillin or ha<itra« 
cin. 

Zinc p(‘roxiih* locally 
after ciebridemeni 
of n(‘crotic ti.ssucn 
Amputation if medi- 
cation fails. 

Amebic infec- 
tion with 
gangrene 

Essential organism: 
Endamoeha his- 

tolytica associated 
with numerous 

streptococci, staph- 
ylococci and fecal 
organisms. 

Usually follows the 
drainage of an ame- 
bic abscess of the 
liver. 

Margins raised and 
everted. 

Granulations have ap- 
pearance of raw 
beef covered with 
shreds of necrotic 
material. 

Glairy pus expressed 
from margins. 

Extensive destruction 
of dermis with un- 
dermining and sec- 
ondary destruction 
of epidermis. Poly- 
morphonuclear ex- 
udation. .Amebae 
and bacteria nu- 
merous in the exu- 
date and in the tis- 
sues. 

Bacitracin systtnnical- 
ly» orally and lo- 
cally. If bacitracin 
fails, intensive ad- 
ministration of eme- 
tine hydrochloride 
intravenously and 
Anayodin by mouth. 
Radical excision of 
the lesion if disease 
is limited to the .skin 
and mcxlication fails, 
OxytetracyeJimn 



Chemotherapy and Antibiotic 

the advancing margin of the amebic lesions has 
been examined bacteriologically onl\ once, and 
the microaerophilic nonhemolytic streptococcus 
was not found. 

Gangrenous impetigo and fusospirochetal 
gangrene of the skin are more easily differen- 
tiated. Progressive bacterial synergistic gangrene 
has often been confused with chronic under- 
mining burrowing ulcer. Dostrovsky and 
Sagher, for example, in their report on “ulcus 
phagedenicum cutis," have undoubtedly in- 
cluded both of these conditions. Idowever, they 
may be clearly differentiated both by their 
clinical course and by careful anaerobic bac- 
teriologic studies. 

TETANUS 

Definifion. Tetanus is a disease of man 
and certain lower animals characterized by local 
spasm or general convulsive contractions of the 
voluntary muscles due to the action of a poison 
produced by a specific bacterial agent, Clos- 
tridium tetani. 

Etiologic Agent. The Cl tetani is a gram- 
positive spore-forming bacillus which is strictly 
anaerobic. The spores are terminal and round 
and are thus easily distinguishable from the 
sporulating anaerobic bacilli of the gas gan- 
grene group. The organism grows only in a 
medium or in an environment with an oxida- 
tion-reduction potential ranging between 0 and 
15. It grows best at 37*^ C. in a medium having 
a pH of 7 to 7.6. Stab cultures in gelatin or 
agar produce a typical ‘mverted fir-tree 
growth,” while on blood agar plates the culture 
spreads as a thin film. It does not ferment 
sugars or digest protein. Its various forms may 
be divided into a number of groups which 
differ in their agglutination reactions (5 main 
types and 4 other rarer types), but all these 
groups produce the same toxin. This has at 
least two fractions, one being hemolytic and 
the other neurotoxic; possibly one fraction 
causes convulsion and the other death. 

The organisms are essentially saprophytic. 
They are frequently found in the feces of 
horses, cattle and sheep but to a considerably 
less extent in the intestinal tract of man, un- 
less be has been fairly recently in close contact 
with domestic animals. A study of the fecal 
discharges of urban dwellers revealed an in- 
cidence of less than 5 pet cent, but a similar 
study of a group of farmers or of soldiers who 
had recently returned from World War I 


Therapy of Surgical Infections 89 

yielded an incidence of 30 to 35 per cent of 
these organisms. 

Tetanus organisms in pure culture are prac- 
tically harmless when injected into the normal 
tissues of susceptible animals, but if the tissues 
arc injured by mechanical or chemical means 
or bv concurrent infection with other bacteria, 
the tetanus bacilli multiply and produce toxin. 

Natnral Infection. Portal of Entry. The 
experimental observation just mentioned prob- 
ably applies to the disease as it develops clini- 
cally in man and in animals, because in al- 
most every case there is some evidence of tissue 
injury or concomitant infection. The organism 
may enter the body through a gunshot or knife 
wound, a compound fracture or any gangrenous 
or traumatized portion of the skin, including a 
bedsore. It may also enter through more trivial 
injuries, such as insect bites or stings, bites of 
animals, blisters from burns or other irritants, 
extraction of teeth or even trivial scratches. 

Development of the Infection. When the 
organisms have been introduced and have 
found conditions favorable for their growth, 
they multiply readily in situ but usually do 
not invade the body. They probably do not mul- 
tiply as rapidly as other organisms, because 
even in well-established infections it may be 
difficult to recover them from the lesion. Occa- 
sionally they have been found in regional 
lymph glands but not in the blood stream or in 
distant organs or tissues. They produce their 
disease in a manner similar to that of diphtheria 
bacilli, by developing a powerful exotoxin, 
which is absorbed and carried to the suscepti- 
ble tissues, where it produces the characteristic 
symptoms. 

Period of Incubation. This varies remark- 
ably and represents the time it takes the or- 
ganisms to grow and produce their toxin plus 
the time it takes for the toxin to attack the 
Susceptible tissues. A few cases have been re- 
ported in which the symptoms appeared within 
twenty-four hours of the injury. In other cases 
the period of incubation has been prolonged 
over a period of weeks, and one case has been 
reported in which the characteristic features of 
the disease did not appear for two hundred and 
thirty-nine days. The greatest number of cases 
develop in seven to fourteen days. 

Symptomatology. There are apparently two 
characteristic groups of symptoms, depending to 
some extent on the location of the portal of 
entry and the manner and speed with which 



90 Chapter 3, Surgical Bacteriology, 

the toxin is produced and absorbed. The fiist 
is called local or ascending and the second gen- 
eral or descending tetanus. In local tetanus 
there is stiffening or twitching of the muscles 
in the region of the wound, which may be so 
mild that it is not recognized as a manifesta- 
tion of tetanus. It may pass off spnntaneoush 
or may gradually increase in se\'erit\ and range 
until it spreads upwmrd, involving the whole 
body. 

In the descending tt^pe the symptoms begin 
first in the small muscles of the face, with stiff- 
ening of the masseter muscles which may 
progress until it is impossible for the patient 
to open his mouth (lockjaw). The muscles of 
the face may pull back the corners of the 
mouth, giving a grimace called the “risiis sar- 
donicus” of Aretaeus. The pharyngeal muscles 
may be imnh^ed, making it difficult for the pa- 
tient to swallow. The muscular spasm gradually 
spreads downward to involve the muscles of 
the neck, chest, back, abdomen and extremi- 
ties. In both the ascending and the descending 
type, when there is extensive stiffening of the 
muscles, the patient exhibits a series of clonic 
or tonic contractions of the muscles, which may 
start in small groups and gradually spread until 
the whole body is thrown into a violent con- 
vulsion. Such attacks are frequently started by 
trivial external stimuli, a mere touching of the 
body with the hand or with the bedclothes, a 
jar of the bed, a sudden increase of light in the 
room or even a loud noise. The convulsions may 
increase in frequency until they are almost 
continuous, and then the inability of the pa- 
tient to relax the diaphragm or the external 
muscles of respiration prevents the intake of 
air, and asphyxia supervenes. It is thought that 
the frequent and more or less continuous con- 
traction of the muscles produces a large quan- 
tity of lactic acid and consequent acidosis, 
which is incompatible with life, but death is 
essentially due to suffocation. The contractions 
of the muscles of mastication may he extremely 
painful because of the pressure exerted on the 
teeth, hut the cramp of other muscles is usually 
not so distressing except for their psychologic 
effect bn a very clear mental state. 

Pathology. When examinations are per- 
formed on man and animals after death due to 
tetanus, no pathologic lesions can be found ex- 
cept in experimental animals to which tre- 
mendous doses of toxin have been given. There 
is apparently no death of the cells of the cen- 
tral nervous system which axe rendered hyper- 


Chemotherapy raid Antibiotic Therapy 

active by tlic toxin nor ol the inusclc cells, 
which are found grossly lo he in a contracted 
stale. In human beings in whom the tliscasc has 
been prolonged through a period oi st'w'ial tla\*s 
and to whom it has been difliciilt to gi\c proper 
nourishment, there is a wasting proci'ss in the 
\'ari<)us organs and tissues ol the hocK, I)ut no 
specific pathologic cliatigcs tun be dcniom 
stratccl. 

/\bcl and his co workers have shown that 
when a minimal lethal dost' or a suhlcthal dose 
of toxin is injected h\ aii} route into cx[)cri 
mental animals, it is rapid!) (akcji up and fixed 
both by the highiv specific tissues and bv the 
nonrcsponsiv'c tissues of llit* both. In these 
eases, although the animal tlies, no toxin can 
be found in the blood and kmph, and no toxin 
can be cictcetcd as such in the tissues of the 
body. IF more than one minimal lethal dost* is 
injected, the excess cart soon all Ih‘ I on nd to he 
present in an unchanged slate in the blood and 
lymph. Any toxin in the tissues is then due 
entirely to the toxin present iti the eontained 
blood and lymph, and no greater eoncentralion 
is found in the central nervous syst<‘in, in the 
nerves or in the muscles th;m is proport iontilely 
present in the other organs itecording to tftc'ir 
blood sujqffy. 

Treatment. U will he seen that the rational 
treatment of tetanus depends on an ac'curate 
knowledge of the pathogenesis of tlie disease 
This is not yet entirely clear, in spite of the 
clinical and cx|)erimcntal investigations carried 
on over a long period of tinu'. Until recent 
years the theory has been generally aeee[)tttl 
that the toxin is produced locally in the region 
of the wound and that it reaches tlu' cvntnd 
nervous .system only by pa.sslng up tlte motor 
nerves to the anterior horn cells of' the cord and 
thence spreading both up and down within the 
cord and backward to involve the sensory n ‘c 
cells. It was thought that whatever toxin vots 
absorbed by the blood and lymph was ths^ 
tributed by the arterial circukidon tet ilie x'ari- 
ous muscles of the body and then in torn ah- 
sorbed by the axis-cylinders td their motor 
nerves. The absorption was said to 1k‘ accom- 
plished either by protoplasmic streaming'^ 
within the axis-cylinder, by way of the ptai- 
ncural lymphatic ducts or up' througli the 
interfibrillar channels. The beginning in the 
face and jaw muscles of the symptoms tif de 
scending or general tetanus 'was explained 
by tbe fact that in these muscles the short- 
est route to the central nervous system was 



91 


Chemotherapy and Antibiotic 

lounci Local teianus in the muscles near the 
porta! of entry was explained by the absorption 
ot the toxin by the motor nein'es in these mus- 
cles, with contraction occurring as soon as the 
toxin reached the motor nerve cells in the 
cord. 

However, a number of investigators brought 
forth clinical and experimental evidence to cast 
doubt on this theory, and more recently' Abel 
and his associates have brought strong evidence 
to light which seems to refute this conception. 
They have called attention to the fact that 
there is no such thing as “protoplasmic stream- 
ing” within the axis-cylinder of the nerves and 
that the perineural lymphatic ducts pass up- 
ward to regional lymph glands and not to the 
spinal cord. Likewise, there is no possibility for 
the toxin to pass up through the tissue spaces 
between the fibers in a nerve bundle. They be- 
licvc that local tetanus is produced by direct 
action of the toxin on muscles in the neighbor- 
hood of the distributing focus and that all the 
rest of the toxin is rapidly taken up through the 
blood capillaries and lymphatic vessels into the 
blood stream and distributed throughout the 
body through the arteries. They believe that 
there is no ‘Tlood-brain barrier” preventing the 
passage of the toxin into the susceptible central 
nervous system tissue and no barrier between 
the blood and other susceptible tissues. They 
do not offer any satisfactory explanations for 
the order in which symptoms appear in the 
descending form of the disease. These impor- 
tant studies have been confirmed by Firor. 

That this problem is still under investigation 
is indicated by the report of Roofe, whose ex- 
periments on guinea pigs seem to indicate 
clearly that the toxin may spread up the neuio- 
fi|:>rillae in the axis-cylinder of the normal scL 
a»' i’ nerve after five minutes of contact, and it 
vid not so spread after the sciatic nerve had 
been exposed and frozen with C 02 ^ snow, 
which produces degeneration of the axis-cylin- 
ders hut docs not alter the blood supply or the 
neurilemma sheath. 

Prophylrtctic Treatment, Opekative. It is 
evident from the foregoing brief review of the 
pathogenesis ot the disease that it is of the 
greatest imi>ortancc to prevent the evolution 
of a lethal dose of the poison. When any con- 
dition exists or when any wound is produced 
which is likely to provide conditions favorable 
For the introduction and the growth ot L . 
temT treatment must he instituted which wdl 
make the establishment of this organism dit- 


Therapy of Surgical Infections 

ficult if not impossible. The surgical procedure 
in the treatment of the wound requires the re- 
moval of all foreign bodies and devitalized tis- 
sue; no attempt should be made to close the 
wound. The margin of excision, of course, 
may ha\'e to be limited, and a compromise may 
be necessary when the wound is in certain ana- 
tomic locations which make extensive excision 
of the part inadvisable, as for example, on the 
face. 

Antiseptics. Various antiseptics ha\'e 
been recc/inmended for use after the excision 
of the wound. Among these agents, probably 
the most important is zinc peroxide, which not 
only inhibits the growth of all anaerobic oi- 
ganisms bv producing a highly oxygenated en- 
\'ironment but also has a detoxifying action on 
the toxin and vet docs not injure tissue. The 
results of treatment with penicillin have been 
equivocal, but, in vitro, the growth of CL 
tetani is inhibited by penicillin. Bacitracin is 
also inhibitory in vitro, and its clinical use is 
clearly indicated. 

Active Immunization. In recent years en- 
couraging efforts have been made to produce 
active immunity in such persons as soldiers who 
are likely to be subjected to wounds contami- 
nated with tetanus organisms. It has been 
found that the injection of toxoid or anatoxin 
(toxin detoxified by formalin or alum pre- 
cipitation) calls forth antitoxin in the body 
of the recipient. Little or no response is seen 
after the first injection; but if the second is 
given three to six weeks later, there is a sharp 
rise in the antitoxin content of the blood 
serum. This is maintained for a variable period 
of months and gradually disappears. If, how- 
ever, a third injection of toxoid is made three 
to six wrecks afterward, there is sudden devel- 
opment of antitoxin which seems to be ade- 
quate to combat almost every natural con- 
tamination with the organism. Thus, if a soldier 
is immunized by three injections of tetanus 
toxoid and later sustains an injury, a '‘booster’ 
dose or series of toxoid injections is considered 
to be more effective as a prophylactic than a 
dose of tetanus antitoxin. The use of toxoid 
practically eliminated tetanus from the French 
army early in World War II. That the Ameri- 
can and British forces were similarly protected 
was amply demonstrated by the low incidence 
of tetanus. Only twelve cases of tetanus oc- 
curred among the American armed forces from 
1941 to 1945. Glenn reported on the high in- 
cidence of this disease among nonimmunized 



92 Chapter 3. Surgical Bacteriology, Chemotherapy and Antibiotic fherupy 


nath'CS during the recapture of iVlanila. llicre 
were 156 cases of tetanus among 1100 wounded 
natives, while not a single case occurred among 
the wounded American soldiers, who sus- 
tained similar injuries in the same environ- 
ment. 

Serotherapy. To all injured or burned 
patients who ha\^e not been immunized with 
toxoid, antitetanic serum must be given. The 
usual prophylactic dose of tetanus antitoxin is 
1500 U.S.P. units, which represents enough 
antitoxin to neutralize 2000 minimum lethal 
doses for a 1 50 pound man. The relative value 
of these prophylactic measures cannot be accu- 
rately estimated, and one can be sure that no 
single measure will prevent tetanus in all cases. 
It was demonstrated beyond the shadow of a 
doubt by the experience of army surgeons in 
World War I that the routine use of antitoxic 
serum was of tremendous value. The high in- 
cidence of tetanus in the early days of the war, 
when antitoxin was not available, as compared 
with the minimal occurrence of the disease 
when the antitoxin was given as a routine 
measure, amply demonstrated its efficacy. When 
conditions were maintained which favored the 
development of tetanus, such as in compound 
fractures or retention of foreign bodies which 
it was impossible to remove, it was found neces- 
sary to repeat this prophylactic injection every 
week or ten days until it was certain that the 
conditions no longer existed. When secondary 
operative procedures had to be carried out for 
war wounds, it was likewise necessary to repeat 
the prophylactic injection, because the trau- 
matism of tissue in which tetanus spores may 
be lying quiescent might reactivate the or- 
ganisms and re-establish conditions favorable 
for their multiplication and the elaboration of 
their toxin. 

Active Treatment. Operative. When the 
initial symptoms of the disease have appeared, 
the first requirement is to remove surgically 
the focus of infection or the ‘koxin factory.” 
This requires complete excision of the wound 
and removal of all foreign bodies and necrotic 
or grossly infected tissue. No attempt should 
be made to close the wound. 

Antiseptics. After the surgical procedure 
the wound area should be flooded with a 
creamy suspension of effective zinc peroxide. 
By effective zinc peroxide is meant the medic- 
inal grade of that product which has been dry 
sterilized according to instructions and which 
when added to sterile distilled water to the 


amount ol 5 gm. in 50 cc. VN'ill settle as <i soli, 
curdy precipitate, leaving the supernatant lliiid 
elear, and will cause the e\a)lLiti()n ol oxvgeii 
within the first hour, with continued e\’t)liition 
during the next twenty-four hours. It is im 
portant to make certain of the eonlaet of this 
creamy suspension with every part ol the 
wound. In many cases it is necessary to pack 
the wound gently wdth line mesh gau/e (u' a!) 
sorbent cotton soaked in the /.ine peroxide 
suspension so as to keep the surlaees ol tin' 
wound apart. 'The dressing should then be c*o\ 
cred over with water-soaked cotton aiul then 
wuth several layers ol petrolatum gau/e to pre 
vent evaporation. 

CiiExioaiiERAPY. rhe sulfonamides art* of 
no help in the treatment of this disease, be 
cause of the susceptibility to penicillin in vitro 
of the organism producing tetanus, this anti 
biotic has been used in the treatment ol estah 
lished tetanus. Favorable results have* ht't'n re 
ported by Weinstein and Wcsselhoeit, (iroec, 
de Lautour and Tripoli. On the other hand, 
Altemeier, who bad the opportunitv t)l treat- 
ing 13 patients in a period of two years, 
could not be convdnccd of tlie ellieaey ol' the 
drug except as it might help to control see 
ondary infections, tdenn used {xmieillin in b 
cases in his series, and all 6 patients died with 
out showing any response to tlic drug. It is 
quite possible that gram-negative rods capable 
of neutralizing penicillin by the formation of 
penicillinase in the wounds iiihibitcxi the fa- 
vorable action of penicillin in these eases. If 
penicillin is used, it should be given in doses 
of 1 million units a day. 

Bacitracin, which is not inhihiled by pcnieil 
linase producers, is also active against CL 
tetani and should be given intramuscularK’ in a 
dosage of 20,000 to 25,000 units every six to 
eight hours, either alone or with penicillin. 
Care must be talten to insure an intake of 
2500 cc. of fluid a day. 

Serotherapy. Further treatment is directccl 
toward the neutralization of the toxin which 
has been distributed throughout the hotly, ih) 
tent antitoxin in measured U.S.P. or interna 
tional units may be introduced subcutaneously, 
intramuscularly, intravenou.sly or intrathcealiy 
and should be given in large quantities within 
the first twenty-four hours. Although many ob- 
servers advocate the intrathecal route, Abel and 
others maintain that it offers no advantage, be 
cause the antitoxin is rapidly absorbed in the 
blood stream from the spinal fluid and does not 



93 


Chemotherapy and Antibiotic Therapy of Surgical Infections 


come ill contact with the toxin already fixed 
within the central nervous system. There are 
no dependable statistics to prove whether or not 
the intrathecal injection is of value. During 
World War I, Bruce gave some statistics for the 
British army showing that the mortality had 
been reduced from 57.7 per cent in 1914 to 
1915, when tetanus antitoxin was not available, 
to 19 per cent in the last period of observa- 
tion (1917). Ihis improvement was due not 
only to the prophylactic use of serum but to 
the improved surgical technique. But in the 
last 100 cases, in which presumably the sur- 
gical technique was the same, the men who 
had received prophylactic serum showed a mor- 
tality of 17.7 per cent, and those wTo had not 
been given prophylactic serum, a mortality of 
28.5 per cent. One would suppose that in the 
active treatment of tetanus with serum, better 
figures for recovery would be found for the 
group receiving large doses of serum on the first 
day in which symptoms appeared, but such is 
not the case. In like manner, if intrathecal 
injections of serum were of any special value, 
one would expect a lower incidence of mor- 
tality in those cases in which it was adminis- 
tered in that manner; but, again, there are no 
convincing figures to prove this point. It must 
be remembered, however, that it is almost im- 
possible to evaluate these measures properly, 
because as a general rule the series cannot be 
comparable. The patients with the most severe 
cases would be likely to receive antitoxin in 
large quantities by every route possible as soon 
as symptoms appeared, and they in turn might 
show a high mortality, while those with mild 
cases for whom serum treatment was post- 
poned, or was given in relatively small doses 
might show a high incidence of recovery. With 
the present limitation of knowledge with re- 
gard to the mode of action and the impossibil- 
ity of estimating the amount of toxin already 
elaborated in any given case, it seems best to 
lay down the following rules for the adminis- 
tration of antitoxin: 

As soon as the diagnosis is made, 20,000 to 
50,000 U.S.P. units should he given in- 
travenously, 10,000 units into the muscles of 
the neighborhood of the wound, if possible, 
and 10,000 units intrathecally after the re- 
moval of an equal amount of cerebrospinal 
fluid. The intravenous and intramuscular doses 
should then be repeated every four hours and 
the intraspinal injection every twenty-four 
hours until the outcome has been definitely set- 


tled. Some advocate the administration of as 
much as 500,000 units in the first twenty-four 
hours, subsequent amounts being determined 
by the response of the patient to the treatment. 

Symptomatic Treatvient. Measures must be 
taken to combat the distressing effects of the 
muscular contractions which recur often, wdth 
increasing frequency, during the progress of 
the disease. Attacks are often brought on by 
various forms of afferent stimuli, which should 
be minimized. The patient should be kept in 
a darkened room removed from all avoidable 
noises. The bed should not be jarred, and the 
patient should be handled gently. If the con- 
tractures become violent, frequent or painful, 
the patient should be kept under the influence 
of sedatives, which also serve to minimize his 
apprehension. The milder forms of sedation 
with the barbituric acid derivatives may not be 
sufficient, but Sodium Amytal is the best of 
these and may prove sufficient for the milder 
spasms. Morphine, which has the deleterious 
effect of repressing respiration, should not be 
used. Graham and Scott favor the use of paral- 
dehyde in doses of 2 to 4 cc. intravenously or 
intramuscularly. 

Godman and Adrian! advocate intravenous 
procaine, in the form of an infusion in a con- 
centration of 0.1 per cent. Procaine alone di- 
minishes the function of the nerve endings, 
both sensory and motor, but it acts centrally as 
a stimulant. This latter action must be counter- 
acted with some sedative. Pentothal may be 
used but Avextin is preferred because of its 
prolonged action. Mephenesin (Tolserol), a 
curare derivative with prolonged action, has 
also been used but the results were not entirely 
satisfactory. By far the safest sedative is Avertin, 
with which the patient may be kept continu- 
ously subdued for many hours, but the dose 
should be limited to from 60 to 80 mg, per 
kilogram of body weight, for larger doses may 
depress the respiration. Under its influence the 
muscles may completely lose their hypertonicity, 
although thi§ is not always possible. The return 
of spasm within the muscles, even before the 
patient has shown evidence of coming out of 
the narcosis, is an indication fox its readminis- 
tration. If spasticity of the respiratory muscles 
or action of the toxin on the center of respira- 
tion becomes manifest, artificial respiration is 
necessary and can best be accomplished with 
the Drinker respirator. Many patients require 
a tracheotomy when a prolonged narcotic is 
administered, the danger of the development 



94 Chapter 3. Surgical Bacteriology, 

of pneumonia becomes great, particularly when 
aeration of the lungs is limited by spasm of the 
respiratory muscles. Feeding the patient during 
the period of prolonged narcosis must be han- 
dled with greatest care, and elimination must 
be effected by rectal treatment. Improvement 
in the patient’s condition is evidenced by an 
increase of the interval between the spasmodic 
seizures and a gradual relaxation of the con- 
tracture and by per tonicity of the muscles. The 
administration of narcotics can then be inter- 
rupted and gradually eliminated. 

The high mortality of this disease after the 
development of symptoms should not lessen 
but should rather increase prompt and effective 
administration of all the aforementioned meth- 
ods of treatment, and these methods should be 
continued until the patient is completely out of 
danger or has succumbed. In many cases, initial 
improvement has caused the surgeon to be un- 
duly optimistic of the outcome, or, on the 
other hand, the continuation of symptoms has 
led him to be unduly pessimistic. More careful 
study of the pathogenesis of the disease is es- 
sential before there can be hope for further 
lowering of the mortality rate. 

Infection has been suck an important de- 
termining factor in the success of surgical op- 
erations in the past and the contribution of 
bacteriology, chemo- and antibiotic therapy so 
important to the progress of surgery, that it 
seems important to provide the student of sur- 
gery with an extensive list of references to 
guide his additional reading. These have been 
chosen with care and are arranged in the order 
in which they correlate with the text 

READING REFERENCES 

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Wrench, G. H,: Lord Lister, His Life and Work. Lon- 
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Sands, H. B.: Antiseptic Surgery. New York M. J. 37: 
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Meleney, F. L.: Infection in Clean Operative Wounds; 
a Nine Year Study. Sure., Gynec. & Obst. 60:264- 
276, 1935. 

Txaub, E. F., Newhall, C. A., and Fuller, J. R.: The 
Value of a New Compound Used in Soap to Reduce 
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Wells, M. W.: Air-Borne Infection. 

J.A.M.A. 107: 

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Hart, D.; Sterilization of Air in Operating Room by 
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Chemotherapy and Antibiotic Therapy 

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Walter, C. W.: A Reliable Control for Steam Sterili/a- 
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Dochez, A. R., Avery, O. T., and Lanccheld, R. C.; 
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Meleney, F. L., Harvey, H. D., and jern, H. Z.: 
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Cutler, E. C., and Ilunt, A. iM.: Postoperatix'c Pul- 
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Sauerbruch, E. F.: Die Chirurgie tier Brustorgane. Ber- 
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O’Brien, E. J.: The Present Status of ThoracoplasW; 
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Lillienthal, H.; Pulmonary Tuberculosis; Recent Typt-’S 
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Churchill, E. D., and Klopstock, R. L.: Lobectomy for 
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Moore, J. A., Murphy, J. D., and Elrod, P. D.: An 
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Himmelstein, A., Berry, F. B., and Read, C. T.: 
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Meleney, F. L., Olpp,^ J., Harvey, H. D., and Zaytzeff- 
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Illingworth, C. F. W.: Types of Gall Bladder Infec- 
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96 Chapter 3. Surgical Bacteriology, Chemotherapy and Antibiotic Therapy 


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97 


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Therapy of Surgical Infections 

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98 Chapter S. Surgical Bacteriology, 

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^ 19 ^ 53 ^ 1859 ^*' ^ 


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an Intestinal Saprophyte. J. Fxper. Med. 16:261 
271, 1922. 

Bruce, D.: Fifth Analysis of Ctiscs ol hlanus I reattal 
in Home Military Hospitals during Part ol Decent 
her, 1916, All January tind I’chruary and Pari of 
March, 1917. Lancet 2:925-428, 1417. 

Abel, J. J.: On Poisons artel Disease ami Some P.\‘[>eri 
ments wdth the Toxin of the Bucilltis ictiinL Science 
79:121-129, 1934. 

Ahel, J. J., Evans, E. A., Jr,, Hainpil, Ib, ami Lee, 
F. C.: Researches on Tentanus: II. riu: To.xin of 
the Bacillus ietemi Is Not Transported to the Centr.t! 
Nervous System by Any Cbmponent of ihe IVaaph 
eral Nerve Trunks. Bulb Johns 1 lopkins I losp. 56: 
84-114, 1935. 

Abel, J, J., Hampil, B., and Jrtnas, A. 1*., Jr,: Re 
searches in Tetanus: HI. Further F,x|HT!meti{s in 
Prove That Tetanus Toxin Is Not (airried in Pcaaph 
eral Nerves to the Central Nervous Svstem. IhiJ, 56; 
317-336, 1935. 

Meyer, H., and Ransom, F.: Untersudumgtm uher den 
Tetanus. Arch. f. exper. Path, u, Phartnakol. 49: 
369-416, 1903, 

Zupnik, L.: Die Pathogenese des TeUuuis. Deutsche 
med. Wchnschr. 32:1999-2004, 1905, 

Firor, W, M.: The Prevention and iVeatoient of 
Tetanus. Am. J. Surg. 46:450-453, 1939. 

Roofe, P. G.: Role of the A.xis Cylinder in TVansport 
of Tetanus Toxin, Science 105:180-181, 1447. 

Meleney, F. L.; Zinc Peroxide in Surgical InF'ctions. 
S. Clin. North America 16:691-711, 1936, 

Gold, H.: Studies on Tetanus Toxoid: I. Active Im 
munization of Allergic Individuals with Tetanus 
Toxoid, Alum Precipitated, Refined, j. Allergy H; 
230-245, 1937; Studies on Tetanus Toxoid; IL^ 
Active Immunization of Normal Persons with Teta 
nus Toxoid, Alum Precipitated, Refined j.A.M.A. 
109:481-484, 1937. 

Cowles, P. B.: Tetanus Immunization. Yale ]. Biol 
Med. 9:409-416, 1937. 



Chemotherapy and Antibiotic Therapy of Surgical Infections 


99 


Lon? A. P., and Sartwell, P. E.: Tetanus in the United 
Sta’tes Armv in World War II. Bull. U. S. Army M. 
Dept. 7.-371-385, 1947. 

Glenn, F.; Tetanus — a Preventable Disease; Includ- 
ine an Experience with Civilian Casualties in the 
Battle for Manila (1945). Ann. Surg. 124:1030- 

1040, 1946. . ^ r. . -n- ■ 

Weinstein, L., and Wesselhoeft, C.: Penicillin^ in 
Treatment of Tetanus; Report of Two Cases. New 
England J. Med. 233:681-684, 19‘45. ^ 

Grove J. L. : Tetanus Treated with Penicillin; Ke- 
coverv. M. J. Australia 1:226-227, 1946. 
de Lautour, G. A.: Tetanus: Two C^es 

Penicillin. New Zealand M. J. 45:425-428, 1946. 
Tritioli, G. J.: Penicillin in Tetanus; Report of Two 
Toxic Reactions Following Its Use ™ 

Cases. New Orleans M. & S. J. 98:451-454, 1946. 


Altemeier, W. A.; Penicillin in Tetanus. J.A.M.A. 

Shiirt^^o?’ 

Serum in the Monkey. Lancet 2:964-966 1917. 

Nicoll. M., Jr.: A Su^ey of O- M J 
of Tetanus and Its Treatment. New \ork State W. J- 

r^G^Tt'S'Scoa T. McN,. No.« o. .1. 
° 'SSinL 4 N«v Engl..d I. M<a. 235, 

tients with Tetanus; Some Clinical Exp^ences mth 
Various Muscle-Relaxmg Agents. J.A.M.A. 

754_756, 1949. ^ ^ ^ ^ 

Drinker P., and Shaw, L. A.: An Apparatus for the 
Prolonged Administration of Artificial Eesp^tiom 
I. A Design for Adults and Children. J. Clin, in 
vestigation 7:229—24/, 1929. 


4 


Shock 


By ISIDOR S. RAVDIN, M.D, and JAMBS E. BCKENI lOI’lE M.l). 

IsiDOR ScHWANER Ravdin, joliu Rlica Biirtou Professor of Sui^^ery at the U iiivcrsity 
of Pemisylvania, is a Hoosier hy birth. lie was educaiccl ut linlicina Lfiiiversity oiid the 
University of Pennsylvania. He Ims directed the Harrison Liihoratory of Siiryjad 
search from which have come many ftiiidafnenial vontrilniiions to surgery, ('.ousidtaiit 
in Stirgery in the Far East during World War II, Dr. Puivdin has played an active role 
as a memher of the Armed Forces Medical Policy Council of the Department of the 
Defense and has an intimate knowledge of the most recent developments in the field 
of surgery with which this chapter deals. 

James Edward Eckenhoff, of Maryland, was edticatcd at the University of Keatuckr 
and received his medical training at the University of Pennsylvania. Actively interested 
in problems of research relating to the field of anesthesiology, he serves as Professor of 
Anesthesiology at the University of Pennsylvania. 


Shock is a common clinical entity, exten- 
sively studied for over a half a century, but 
many of the basic mechanisms involved are still 
incompletely understood. Shock is usually en- 
visioned as accompanying or following trauma; 
indeed, a great impetus for its study has been 
the relatively concentrated mass wounding ac- 
companying warfare. Elowevcr, the syndrome 
is not confined to trauma, nor to surgery, but is 
frequently seen in conjunction with medical, 
neurologic and even psychiatric disorders. This 
implies extensive ramifications of the etiologic 
processes of shock and casts doubt upon a 
single exciting cause. 

Shock has been variously qualified as sur- 
gical shock, wound shock, hemorrhagic shock 
and neurogenic shock. Such terms are likely to 
refer to probable initiating causes. The estab- 
lished clinical picture, however, is essentially 
the same under all of these conditions. In each 
instance, the additional qualifiications of im- 
pending shock and irreversible shock are more 
helpful. The first qualification implies that the 
patient does not appear to be in shock, but does 


demonstrate signs and synijitoins suggesting 
that shock will occur within a short time unless 
preventive steps are taken. Wlien the svinp 
toms of shock have persisted sudieiently long to , 
preclude recovery in spite o( thto'apy, irreversi' 
ble shock has occurred. The fieriod rcc|uirccl to 
produce irreversibility is variable; shock in the 
patient in poor physical condition may become 
irreversible within minutes. In a* usually 
healthy but recently injured yDung adult, irre 
vcrsiblc shock may be delayed. 

The clinical picture of shock is well known 
and widely taught. The patient’s skin is pale, 
cold, and moist. Respirations arc sliallow, ra[)i(l, 
and often grunting in character. I lovvevcr, in 
profound shock, the respiration rate may be 
only 2 to 3 per minute. Occasionally, the lips 
and fingernails are sTghtly cyanotic. 'Fhe j)i!lse 
is weak and rapid, flic blood pressure is low. 
Urine formation is scanty or absent. Thirst is a 
common feature. Complaints of pain may be ^ 
absent except when the patient is moved/ Ap^ 
prehension and restlessness arc usually tlis 
played. The sensorium may be cloudedf 


Page 100 



Shock 


Etiology. Some exciting factors of shock 
are fairly clear-cut. The most obvious and most 
common is acute hemorrhage, or protracted 
fluid loss. The early mechanisms of shock fol- 
lowing trauma without blood loss, neurogenic 
shock appearing after cranial injury, cardio- 
genic shock preceded by myocardial infarction, 
or shock occurring from toxicity or poisoning, 
are not clearly understood. Least well explained 
is why shock becomes irreversible. 

Originally, attempts were made to implicate 
a single factor in the development of irreversi- 
ble shock. Early theories suggested that the 
major defect was either inadequate cardiac out- 
put, prolonged maintenance of hypotension be- 
cause of regional vasodilatation, a reduced 
blood volume due to leakage of fluid from the 
blood vessels, or vascular depression produced 
by toxic material released from wounds. Today 
the consensus appears to be that no one factor 
predominates, but that many things may con- 
tribute to produce an inadequate circulation 
. following which irreversible shock can occur. 
Freeman has presented this chain of events 
diagrammatically as shown in Figure 1. 

A resume of the circulatory response to stress 
is helpful for orientation. Table 1 is a modified 
version of Bazetfls calculation of the distribu- 
tion of the circulation and the uptake of oxy- 
gen by organ systems. It is apparent that, under 
normal conditions, the major demand for blood 
flow and oxygen uptake is by vital organs 
(brain, heart, and hepatic portal system), yet 
these represent only 7 per cent of the total 
body weight. On the other hand, the principal 
mass of the body (skeletal muscle, connective 
tissue, bone, and skin) representing 93 per cent 
of the total w^eight receives only 30 per cent of 


101 

the cardiac output, and 40 per cent of the oxy- 
gen intake (Table 2). 

Under conditions of stress, widespread 
changes occur in blood volume distribution. 
With muscular exercise, blood flow to muscle 
increases as does oxygen consumption. Such 
changes are met by diminution in flow to other 
tissues, notably the kidney. These are normal 
reflex mechanisms. 

Following hemorrhage, blood flow to vital 
organs is maintained at the expense of the prin- 
cipal mass of body tissue. Initially, blood pres- 
sure is maintained by generalized peripheral 
vasoconstriction which simultaneously diverts 
blood from the peripheral circulatory beds (e.g., 
muscle, skin) to vital organs. Kidney Hood 
flow diminishes most sharply and with the 
slightest stress, even with emotion. As blood 
volume is reduced by hemorrhage, blood flow 
through nonvital tissue is gradually reduced by 
increasing vasoconstriction until finally a peak 
of compensation may be reached when the 
functional circulation consists essentially of 
blood flow to and from the brain, heart and 
liver. Evidence suggests that finally even the 
liver may be shunted out of the circulation, and 
practically all blood flow from the inferior vena 
cava ceases, with flow in the superior vena cava 
persisting. This implies that under these con- 
ditions, the brain continues to be supplied with 
a minimal amount of Hood. 

While the precise chain of events leading to 
irreversible shock is not understood, the com- 
mon denominator is a reduced effective blood 
volume. In hemorrhage, the factor responsible 
for the reduced blood volume is clear, but 
when major hemorrhage is not present, the 
cause of hypovolemia is obscure. The answer 


Hemorrhage 

Dehydration 

Exudation 



I Blood Pressure 


V asocons tr iction 


Low Blood Volume 


Loss of Plasma 

1 


Tissue 



Pain 

Cold 

Fear 

Asphyxia 


1 

Low Blood Flow 


Vascular Stasis 


Asphyxia 

Figure 1 . Diagrammatic representation of chain of events contributing to the production of inadequate cir- 
culation following which teyemhle shock can occur. 



Chapter 4, Shock 


102 

probably lies in the interpretation of ‘"effective” 
blood volume* 

Formerly, it was believed that, in the ab- 
sence of significant hemorrhage, blood volume 
was reduced by generalized leakage of fluid 
from blood vessels into tissue. Blalock and his 
associates were the first to prove that general- 
ized leakage need not occur for hypovolemia to 
appear in shock. More recent evidence indi- 
cates that blood may become trapped within 
peripheral blood vessels, and thus become lost 
to the circulation so far as the prime purpose 
of circulating blood is concerned, i.e., transpor- 
tation of ox 7 gen, foodstuffs and metabolic prod- 
ucts. The first sign of slowing blood flow and 
impending shock at operation may be increas- 
ing venous oxygen desaturation. This may oc- 
cur despite a satisfactorily maintained blood 
pressure or pulse, and without evidence of re- 
duced arterial oxygen concentration. It signifies 
that blood is passing through the capillaries so 
slowly that a greater than normal amount of 
oxygen is being withdrawn from it. It also sug- 
gests marked arteriolar compensation in order 
to maintain the blood pressure. 

Zweifach and his associates have demon- 
strated the activity of precapillary arterioles, 
capillaries and venules in the rat mesentery 
during normal conditions and in hemorrhagic 
shock. Normally, all capillaries do not function 
simultaneously, but with stress every channel 


opens up, tremendously increasing the capacity 
for blood. As blood flow slows, these l essels be 
come engorged with blood, flow finally ceases 
and in some areas the capillary bed is by -passed 
trapping or “sequestering" significant c|uantitie 
of blood. This removes blood contained withir 
the trapped circulation from the “eflective’ 
blood volume. It must be remembered, how 
ever, that the applicability of these ohseri alioni 
to all capillary beds has not beea proved. 

There are no studies to indicate ewn the ap 
proximate amount of blood Ivbieh can he con- 
tained within vascular beds whose tone and 
reactivity have been abolished by aivfxia or uiv 
known factors. Plcthvsmographic studies ha\’e 
indicated that simple warming ol' the legs can 
increase the volume of blood within these parts 
by 500 cc. or more. Investigations upon 
wounded soldiers in shock have demonstrated 
the need for infusion of vast cjuantities of blood 
in order to maintain blood pressure. In Korea 
it was not uncommon to administer twice, or 
even more, the patient’s normal blood \'olume, 
even though there w^as no longer evidence of 
active bleeding. Attempts to locate large vol- 
umes of sequestered bfood by means of chronv 
ium-tagged red cells, or by means of the Fvans 
blue dye technique, have failed, but tlu' evi- 
dence is far from conclusive. Chromium-tagged 
red cells may be rapidly dcstro5^xl. Also, ilw 
tagged cells or dye may be unabie to reach the 


^ TABLE 1. REGIONAL BLOOD FLOW AND OXYGEN CONSUMPTION 


WEIGHT 

(KG.) 


PERCENTAGE 

OF 

TOTAL WT. 


ORGAN 
BLOOD FLOW 

(gc./min.) 


CARDIAC 

OUTPUT 

(%) 


ORGAN 

OXYGEN 

UPTAKE 

(cc./min.) 


TOTAL 

UPTAKE 


Brain 

Heart 

Hepatic-portal 

Kidney 

Skeletal muscle 
Skin 

Residual tissue 


1.4 

0.3 

2.6 

0.3 

31.0 

3.6 

23.8 


2,2 

0.5 

4.1 

0.5 

49.2 

5.7 

37.8 


750 

255 

1500 

420 

840 

460 

380 


13.9 

4,7 

27.8 

23,3 

15.6 

8.4 

6.4 


46.2 

29.1 

51.0 

17.6 

49.6 
10.9 

50.0 


22.9 

11.6 

20,4 

5.0 

20.0 

4.B 


TABLE 2. COMPARISON OF REGIONAL BLOOD FLOW AND OXYGEN CONSUMPTION 'It) 
VITAL ORGANS AND OTHER TISSUE 

REGION 

WEIGHT percentage 
(kg.) 

TOTAL WT. 

ORGAN 

BLOOD FLOW 

(cc./min.) 

CARDIAC 

OUTPUT 

(%) 

ORGAN 

OXYGEN 

UPTAKE 

(cg./min.) 

TO'l'AL 

OXYGEN 

UPTAKE 

(%) 

Vital organs 

(excluding kidney) 
Other tissue » 

4.3 

58,4 

6.8 

92.7 

2506 

1680 

46.4 

30.4 

126.3 

110.5 

54.9 

40,1 



Shock 103 


TABLE 3. EFFECT OF ANTIBIOTICS ADMINISTERED OR.ALLY 


DRUG 

DOGS 

(no.) 

PERIOD OF SHOCK 

(hours) 

survivors 

None 

185 

4 8 

25 (14%) 

Aureomycin 

25 

7.0 

22 (88%) 

Neomycin 

25 

7.2 

22 (88%) 

Penicillin 

19 

7.1 

12 (63%) 


sequestered blood, thus preventing complete 
dilution. Evidence in favor of sequestering was 
obtained from postmortem studies of men dying 
in shock in spite of massive transfusion. These 
studies revealed skeletal muscle, liver and lungs 
choked with blood. 

Obviously, these factors all work in the same 
direction, namely, the production of annnade- 
quate circulation.. The lowered blood* volume 
leads to a decreased cardiac output. Sequestered 
blood and diminished capillary blood flow 
lower venous pressure and diminish venous re- 
turn, which likewise contribute to a reduced 
cardiac output. With prolonged hypotension, 
Wiggers has found that the myocardium itself 
may be damaged, and even though the blood 
volume be restored, the myocardium is unable 
to recover. Myocardial failure then relentlessly 
progresses to death. ' 

There are other factors which play a part in 
the progressive decline of the circulation, but 
their exact role has not been defined. Several 
lines of investigation have been followed, some 
of which are challenging. These include: . 

The balance between VEM (vasoexciton 
material) and VDM (vasodejpressor material) a 
Shorr and his co-workers have demonstrated! 
the existence of a vasoexcitor principle elabo- 1 
rated by the kidney and appearing in the blood! 
stream following renal hypoxia. VEM seems to? 
be integrated with adrenal cortical and sym- 
pathetic nervous system activity. It appears 
following hemorrhage, or in impending shock. 
During this phase, WRTJde^^^^^ 
and formed in the liverTalso appears but under 
aerobic conditions the liver transfonns_it into 
an inactive form.’*^*WifE €e®iorati6n of the 
hepatic blood supply, oxygen lack occurs, the 
transformation of VDM fails, and ferritin ap- 
pears in the systemic cifchlation. Experi- 
mentally, in irreversible shock, VDM has been 
detected in large quantities. However, blood 
samples withdrawn from Korean casualties in 
shock have failed to yield ferritin in significant 
quantities. 

Bacterial factor. Fine and his associates 


have observed that in dogs treated with anti- 
biotics prior to hemorrhagic shock, the survival 
rate w^as higher than in untreated shocked dogs 
(Table 3). They have postulated that, during 
shock, bacteria flourish and, by either direct 
action or by toxic metabolites, produce circu- 
latory changes leading to irreversible shock. 
Antibiotics minimize and prevent this action. 
The antibiotics are more effective orally than 
parenterally, presumably because of the influ- 
ence upon the intestinal bacterial flora. Like- 
wise, some antibiotics are more effective upon 
organisms of the intestinal flora than are others. 

There is evidence that the ability of antibiot- 
ics to prevent irreversible shock may be princip- 
ally a species effect. The tissues of rats, cats and 
dogs are not sterile, whereas those of man, 
except for the gastrointestinal tract, are. Factors 
preventing the growth of bacteria already lo- 
cated in tissue may not be significant when 
applied to species whose tissues are not contami- 
nated. Nevertheless, the bacterial factor may ' 
be important in certain types of shock in man, 
such as that accompanying peritonitis, burns 
and massive tissue destruction. It seems more 
difficult to implicate the factor in cardiocircula- 
tory or neurogenic shock. 

Autonomic blocking agents. Evidence has 
accumulated to show that certain of the auto- 
nomic blocking agents are of value in prevent- 
ing, or retarding, the onset of irreyersible, shock” 
in animals. Among the foremost of these agents 
are chlorpromazi^, Dibenz yline and hexa- 
metSE3unrAtropinenKar~generally been in- 
effective. All of these drugs are protective, if 
given prior to exposure to traumatic or hemor- 
rhagic shock, but are ineffective if administered 
after trauma has been inflicted or shock has de- 
veloped. The theory of the use of autonomic 
blocking agents is as follows: During shock, 
vasoconstriction occurs. Because of this, capil- 
lary circulation is reduced, tissue perfusion 
becomes inadequate, anoxic damage occurs, 
vessel reactivity is lost, and, finally, blood is 
sequestered within capillaries. If vasoconstric- 
tion could be minimized or prevented by the 



104 


Chapter 4, Shock 


use of autonomic blocking agents, tissue per- 
fusion could be maintained even though arterial 
pressure is lowered. 

So long as the blood volume is maintained 
within reasonable limits, the theory is feasible. 
It is common to see patients with lowered blood 
pressure^ without vasoconstriction 'who experi- 
ence litfle difficulty. The recent use ot hypo- 
tensive anesthetic techniques has popularized 
this ' ehtity. However, if vasodilatation occurs 
in the patient who has lost considerable blood 
without replacement, r the circulatory beds in- 
the skill, muscle and elsewhere are kept patent 
at the expense of the circulation in the vital 
organs. "As a consequence, cardiac, cerebral, 
hepatic and renal complications may develop 
earlier and with more disastrous results. 

Influence of metabolites. In the early 
phases of shock, metabolites do not appear to 
play a part in the development of irreversibility. 
The metabolic derangements are principally 
those which follow progressive tissue anoxia. 
As irreversibility develops, however, the ac- 
cumulation of metabolites may assume a more 
important role. An interesting field of investi- 
gation in this regard concerns the importance 
of rising blood ammonia levels. Experimentally, 
it has been demonstrated that there is an in- 
creased production of ammonia in the kidneys 
and intestines in shock. The liver loses its ahd- 
ity tcTutilize the ammonia to synthesize utea, 
presumably because of hypoxic parenchymal 
damage. As a result, blood ammonia rises sig- 
nificantly. Efforts are being made at present to 
evaluate the significance of this observation. 

Role of the adrenal cortex. The liberation 
of adrenal cortical steroids is one of the mechan- 
isms by which homeostasis is maintained. In 
the absence of the adrenal cortex, or when 
adrenal cortical reserves are limited, the re- 
sponse of the vascular system to stress such as 
shock may be minimal. Under such conditions, 
the administration of adrenal cortical steroids 
may replenish the depleted stores and restore 
the reactivity of blood vessels to Z-norepineph- 
rine and possibly epinephrine. The importance 
of this factor has notH)een completely evalu- 
ated. In the usually healthy individual sud- 
denly wounded, followed by ^he development 
of shock, the adrenal cortical response has 
usually been foutrd to be normal. Omthe other 
“hand, adequate data have been obtained from 
the chtonically ill individual to indicate a 
diminished adrenal corticosteroid level. In these 
people, the circulatory response to shock is often 


poor, but may be improved hy the intravenous 
injection of corticosteroids. 

Circulatory homeostasis is dependent upon 
many and varied lactors: tin heart must be 
adequatefthe blood x'cssels must be patent and 
reactive; the lungs must be functional and oxy- 
gen supply sufficient; there must b(‘ sufficient 
blood to circulate; the cenk’r controlling nerv- 
ous impulses (brain) must be ptu'f’onning satis- 
lactorily; the addition of \'ital substances, such 
as corticosteroids, to the blood stream must be 
optimal and, the mechanisms to alter metabolic 
products and to eliminate waste substances must 
be functioning satisfactorily. Intcrle-rcnce with 
the aforementioned system' at i\hy point reduces 
the ability of the body to "withstand slroek and 
hastens the' onset of irreversibility. Some factors 
are more important than others, hor instance, 
the patient with a sudden myocardial infarc- 
tion may go into shock rapidly. Other factors 
may he of less immediate importance but may 
ultimately lead to shock. 

Treatment Obviously, the most important 
factor in the treatment of shock is its preven- 
tion. This is not alwa\’s possible; Idrinstancc^ 
the shock which follows sudden myocardial in- 
farction, or .that appearing after cranial injury. 
However, much can be done to prc\'ent shock 
accompanying trauma, operations, infections 
and burns. In hemorrhage, the important thing 
is to stop bleeding whether it is external or in- 
ternal. 

The idea of anticipating the possibilities of 
wound shock in soldiers by the routine preven- 
tive use of chlorpromazine is intriguing. If 
chlorpromazine had no undesirable side effects, 
this use might he feasible. However, the drug 
is a depressant in its own right, and a decrease 
in mental acuity in all soldiers might counter- 
balance the possibilities of protection from 
shock in a few. Nevertheless, in civilian sur- 
gical practice, fhe use of chlorpromazine pre- 
operatively in patients in whom significant j 
blood loss is expected may be worthwhile, dlae 
value of such ^protection awaits furtlier .study. 

The movement of wounded, acutely ill, un- 
conscious or anesthetized patients mustffic ac- ! 
complished with great care. If shock is "ap ; 
parent, it is better to postpone movement than 
to jeopardize the patient’s life. Unnecessary* or ! 
rough movement may produce sudden, severe ! 
hypotension or even cardiac arrest under these ; 
circumstances. The same caution should apply 



Shock 


105 


to movement of any unconscious or anesthe- such as the ‘‘dry sponge method,” should be 

tized patient. Hypotension is often seen follow- used. In this method, the dry weight of the 

ing transference of these patients from operat- sponge is subtracted from the blood-soaked 

ing table to litter or bed. VVdien mo\ cment is weight, the difference in grams approximating 

accomplished, it should be after broken bones the amount of blood in cubic centimeters con- 

have been splinted or properly supported. Pain, taine’d in the sponge. While not completely 

however, is not the sole cause of hypotension, accurate, it can be used as a suitable index for 

as is evident from the fact that anesthetized blood replacement! 

patients demonstrate it. The answer appears Careful preparation of patients for operation 
to lie in the loss of vasomotor control. will minimize the occurrence of shock in the 

Few patients with trauma require opiates for operating roomr Blo od v olu me studi es are use- 

comfort. A relatively small proportion of se- ful, particularly in the. elderly, sedentary, or 

verely wounded men complain 'of pain, and the chronically ill patient who is to .have a 

pain should be the principal indication for the major operative procedure. Often these groups 

use of narcotics. These agents depress the re- will be found to ha\^e siginficmit h ypovolemia , 

flex control of the circulation. InHhock, im- {l^ransfusion prior to operation __under these, 
pending shbek, or situations in which surgical circumstanc es may ..ypi:ewenL-.Qi„ iiuiuinke.--die^ 
shock may occur, circulatory reflexes should "onset Tf shock. 

be functioning maximally^ When opiates must .'^|)''''OrTrTahnorhe dogmatic about the amount 
be used for pain in shock, they should be in- "^of blood loss tolerated without need for re- 
jected intravenously in small doses. Drugs placement. The healthy -adult ■ cairTose 50Q''to 
injected subcutaneously or ihtramus^cularly may 800 cc. of blood MtkQ.uLJQ££d Jor-.^€pfecnTrent, 
not he absorbed by the bloodstream owing to The elderly or acutely ill patient may not toler- 
the inadequate circulation. ate such a loss. The need for blood replace- 

The principal means of preventing shock is ment is usually indicated by the appearance 
to keep the blood volume within normal limits, of hypotension ^ith ..tachycardia- However, 
In all patients who have been injured and in neither of these symptoms nee'd appear. In 
whom shock may occur, in those undergoing general, if the loss exceeds 500 cc., replace- 
major surgery, and in those first seen in shock, ment is indicatedj either with a " plasm a ex- 
intravenous infusions should be instituted, pander or whth whole _blopcL..Jf the loss ex- 
Great care and foresight must be used in the ceeds 1000 cc., whole blood replacement of 
placement of intravenous needles or cannulae. at least 500 cc. is probably indicated. The 
These must Be of a size adequate to allow patient in severe shock needs Mood. In the 
infusion of large quantities of blood within maintenance of Mood volume by replacement 

short periods of time. Effort must not be wasted of minor blood loss, plasma expanders „.,bave 

in persistent attempts at venipuncture in pa- value iiy severe hemorrhage; they complement 
tients in impending shock. The vein should be the use of whole blood. ^Constant watchfulness 
exposed surgically and cannulated under direct by the surgeon and anesthesiologist, with par- 
vision. Both surgeons and anesthesiologists ticular attention to fluid replacement, will do 

should be facile in performing these opera- much to prevent surgical or hemorrhagic shock, 

tions. The largest stores of blood or plasma Shock may be averted following sudden 
expanders are of little consequence unless the hemorrhage, if th e patient's leg s are elevated, 
means for getting the material into the patient The amou nt of Mood estimated to be r eturned 
are available. In Korea, it has been necessary to the syste mic^ ciraxTation by tKisHnaneuver 
to infuse as much as 4500 cc. of blood within may equal or exceed 5 0 0 cc.T!Qwevef71 ! vaso- 
a thirty-five minute period in order to keep a constriction has previouSTy signifi- 

patient in shock alive. In severe shock, or cant degree, little blood may be contained in 
when major hemorrhage is expected, more than the extremities and elevation of the legs, 
one intravenous route should be "provided so th erefore, may be of little vihi^ . It has gener- 
that the required J amount of blood can be ally been assumed thatthe optimal position 
administered. for the patient with h ypotens.lQn , or impending 

Surgeons and anesthesiologists should be- shock, ppsition. This 

come more skilled in estimating blood loss. In facilitates venous return and may improve 

major surgical procedures associated with non- circulation to the brain. Data to support this 
siderable Mood loss; a mote accurate technjque, belief are lacking. 



106 


Chapter 4. Shock 


Conversely, caution should be exercised 
when, after a patient has been operated upon 
in the lithotomy position, the legs are put 
down. Often, this is accompanied by a pre- 
cipitous fall in blood pressure due to filling of 
peripheral vascular channels. This can be 
minimized by wrapping the legs with elastic 
bandages prior to lowering the legs. 

Hypoxic damage may be averted or mini- 
mized in impending shock if the oxygen sup- 
plies to the body are increased. This can be 
accomplished by increasing the oxygen con- 
centration of the inspired gas either by means 
of a nasal catheter, or by a mask. The former 
method, with the catheter at the tip of the 
epiglottis and with an oxygen flow of 6 liters 
per minute, will insure an oxygen concentra- 
tion ill the inspired air of about 40 to 45 per 
cent. The latter method, if properly applied, 
will supply 90 to 100 per cent oxygen. The 
circulation time becomes slower as the blood 
volume is reduced. The closer a patient ap-‘“ 
proaches a shock sj:ate, the more completely 
his blood is desaturated of oxygen following 
its passage through the capillaries.' Therefore, 
the greater the oxygen concentration in the 
arterial blood, the more there is available to 
tissues. All hypotensive patients, whether -in 
shock or not, should be given oxygen for this 
reason. 

In patients who have had chronic illnesses, 
or those who have shown signs of adrenal 
insufficiency and iix. whom major surgery is 
contemplated, adrenal cortical extracts may- be 
of value for preoperative preparation. These 
may improve the responsitivity of the circula- 
tion to endogenous I-norepinephrine or epineph-'^ 
rine and to stress in general". They may also 
prevent the appearance of shock. - 

Careful anesthetic maiwgement will mini- 
mize the occurrence of shock. Prolonged deep 
planes of anesthesia predispose to shock, par- 
ticularly iflhe anesthesia is accompanied by 
rough surgical manipulation and fluid loss. 
Deep anesthesia depresses the adrenal cortical 
response and epinephrine stores may be ex- 
hausted. This has been found true in deep 
ether anesthesia, and probably obtains in the 
lower planes of anesthesia with any agent. 
The depth of anesthesia should never exceed 
that needed to produce satisfactory operating 
conditions. 

The immediate treatment of shock centers 
around a few essentials. These are: 

The intravenous administration of blood. 


The blood should be given rapidly and con- 
tinuously until the blood pressure returns 
within normal limits--and the symptoms of. 
shock begin to abate^ There is considerable 
disagreement concerning the value of intra- 
arterial versus intravenous transfusions of 
blood. The proponents of intra-arterial trans- 
fusion argue that blood is placed in the best 
position to enhance coronary and ccre!)ral blood 
flow, and in general to raise arterial blood 
pressure- In practice, however, one should real- 
ize that not'-nfore than 200 cc. of blood per 
minute can be pumped through an intra-arterial 
cannula, whereas the heart ejects up to 5000 
cc. per minute. In sliOck, cardiac output and 
venous return are low. I’hercfore, there may 
be greater advantage in' infusing large volumes 
of blood into the veins. 

In usually healthy adults in shock, there 
is little danger pf overtransfusion and produc- 
tion of pulmonary edema. 1 lowever, in the 
elderly or chronically ill patient, the fxxssibility 
is greater. In general, if the blood pressure 
remains low, it is safe to infuse blood at a rapid 
rate until the blood pressure has returned to 
physiologic levels. The infusion should then 
be continued at a slower rate. 

Plasma expanders should bo used in the 
absence of blood, or while blood is being 
crossmatched. However, it is unlikely that 
shock can be completely satisfactorily treated 
without the administration of blood. 

Oxygen. A high concentration of oxygen 
should be administered. A nasal catheter will 
produce a 40 to 45 per cent concentration in 
the inspired air. A bag and mask if properly 
arranged with a high flow rate will insure 
nearly 100 per cent. The latter concentration 
is desirable in treating shock, although the 
mask is more uncomfortable for the patient. 

Position. A slightly head-down position 
is probably most beneficial to the patient. If 
the tilt is too great, the patient^s respiration 
may be compromised by the abdominal organs 
pushing the diaphragm upward, thus reducing 
tidal exchange. 

It is not necessary, nor is it wise, to apply 
heat to the patient's body during treatment 
This dilates cutaneous blood vessels and may 
interfere with the maintenance of essential 
circulation. As blood volume is replaced, sur- 
face warming can be accomplished gradually. 
Hypothermia has been advocated for the treat- 
ment of patients in shock. At present, there 
are few data to support this contention. Pub- 



Shock 


107 


lished work suggests that hypothermia alone 
is o£ no greater benefit than is chlorpromazine 
alone. 

Vasopressor drugs. Previously, it was be- 
lieved that vasopressor drugs had no place in 
the therapy of shock. There is evidence now, 
however, that pressor drugs may be of value 
as a temporary expedient combined with the 
simultaneous administration of blood. The 
theory of the use of vasopressors is to produce 
vascular constriction to accommodate the re- 
duced blood volume; as the blood volume is 
increased, the need for pressor drugs should 
be reduced. 

The ideal drugs for this use would be those 
with maximal peripheral constrictor effect and 
minimal cardiac or cerebral stimulant action. 
The most potent agent meeting these require- 
ments is Z-norepinephrine. This drug is a pow- 
erful peripheral vasoconstrictor which reduces 
the size of the peripheral circulatory bed, raises 
the blood pressure, and facilitates venous re- 
turn. It has some myocardial stimulant effect, 
but this does not appear to be as prominent as 
the peripheral effect. Z-Norepinephrine may 
produce an effect when all other drugs have 
failed. Vasopressor therapy is not a substitute 
for blood replacement, but should be considered 
a stopgap measure to be used along with 
blood. Attempts should be made to withdraw 
support by pressor drugs as soon as a reasonable 
blood pressure can be maintained. 

The usual method for administering Z-nor- 
epinephrine is to dilute 4 mg. of the drug in 
1 liter of saline or glucose. This concentration 
can be increased at will; the highest concen- 
tration we have employed has been 64 mg. per 
liter. Its effect is manifest within seconds after 
beginning the intravenous infusion, and dis- 
appears within minutes of termination. The 
rate of flow must be carefully regulated to 
keep the blood pressure at the desired level. 
One must be certain that the injection is intra- 
venous and not paravenous, since the latter may 
result in tissue slough. This appears most com- 
monly after injection into the veins of the 
lower limbs, but has been observed in the 
arms. One should never inject I-norepinephrine 
intra-arterially. 

When is the patient who is in shock, or who 
has been in shock, ready for operation? There 
are no definitive tests to suggest the patient's 
ability to withstand operation after he has been 
in shock or while he is in shock. A recently 
advocated test is one wherein the patient 


thought to be ready for operation is tilted in 
the head-up position for five minutes. If the 
blood pressure remains stable, the patient is 
likely to withstand operation well. However, 
if the patient becomes hypotensive with the 
tilt, further preparation is necessary. 

Another suggested test is to inject intraven- 
ously a small amount of epinephrine or Z-nor- 
epinephrine and observe the response of the 
patient s blood pressure. If there is no response, 
the patient is probably not ready for operation. 
If his blood pressure* responds satisfactorily, he 
should withstand operation. 

What are the problems of management of 
these patients during operation? A severely 
wounded patient, or a patient in shock or 
impending shock, anesthetized by an inade- 
quately trained technician and operated upon 
by a surgeon of limited experience, has a 
greater chance of dying during operation than 
would the same individual in the hands of an 
experienced anesthesiologist and surgeon. Too 
often the problems of anesthesia and surgery 
for patients in shock are learned by sad 
experience rather than from first-hand instruc- 
tion from physicians who have already learned 
the fundamentals of treating patients in shock. 
This has been particularly true in times of 
war. 

The problems of management can be divided 
into those pertaining to anesthesia and those 
relating to surgery. For the former, the follow- 
ing facts are of especial significance. Opiates 
should be omitted preanesthetically since they 
may predispose to further hypotension. There 
are abundant data showing that opiates cause 
respiratory and circulatory depression. Under 
conditions of stress, it would be desirable to 
avoid such depression and to have the circu- 
latory system at its peak of reactivity. There is 
little need for opiates and the hazards follow- 
ing their use are great. 

An anesthetist must be aware that minimal 
amounts of anesthetic agents are required for 
patients in shock. In this condition, the circu- 
lation to the major portion of the body is absent 
or minimal as discussed earlier in reference to 
Table 1. Therefore, the brain and other vital 
organs receive most of the administered anes- 
thetic agents. It is apparent why an overdose 
of anesthetic agent readily occurs. Patients who 
have been in shock, or are in shock, may not 
tolerate any anesthetic. Occasionally, even the 
mildest and most expertly administered anes- 
thetic will convert shock to irreversible shock 



Chapter 4, Shock 


108 

or to death. Cyclopropane is probably the 
anesthetic agent of choice for patients in shock. 
Recent work suggests that, if possible, ether is 
to be avoided since it is a myocardial and 
circulatory depressant in the absence of suffi- 
cient stores of epinephrine within the body, 
such as may occur during shock. Thiopental 
has likewise been incriminated for its depres- 
sant abilities in the severely ill or wounded 
patient. Muscle relaxants are rarely needed 
in the shock patient. Whatever agent or 
method is used, ventilation should be adequate, 
oxygen concentration kept high, and hyper- 
capnia prevented. 

Frequently, the first sign of worsening of a 
shocked patient’s condition during anesthesia 
and surgery is the observation that decreasing 
quantities of anesthetic agents are required to 
keep the patient anesthetized. Failure of the 
anesthesiologist to realize this fact, or to appre- 
hend the sign, will lead to a delay in the insti- 
tution of treatment and the demise of the 
patient. 

From the surgical viewpoint, it must be 
pointed out that speed is essential in perform- 
ing operations upon patients in shock. Defini- 
tive surgery must be deferred until the patient 
is in better condition. The mortality rate asso- 
ciated with prolonged surgery in these situa- 
tions will always remain high. The surgeon 
must be gentle with his manipulations. Rough- 
ness combined with the mandatory light plane 
of anesthesia may give rise to disastrous trac- 
tion reflexes-disastrous in the sense that fur- 
ther hypotension or sudden cardiac arrest may 
occur, or in that it may become necessary to 
maintain a deeper plane of anesthesia to avoid 


reflex activity. For alxlominul operations, mini- 
mal retraction should be employed, since this 
too, may impede venous return to the heart. 

Carclul observation of patic'iits in shock must 
be continued into the immediate jtostoperatke 
period. As mentioned prc\a'ousiy, movement of 
patients in shtx'k, or under anesthesia, must le 
accomplished with caution and gentleness. Sud- 
den turning or shifting of position ean result 
in further h}'pc)tensi()n, deepening of shody 
and death. Oxygen should he administered 
constantly. Electrolyte studies must he made in 
order to detect and treat clehcicncy and c'xcesses 
of any particular ion. Opiates and sedatives 
must he minimized or avoided. Usualiv, these 
patients are more restless Irom hypotension and 
relative hypoxia than from pain. CAnsecpiently, 
small doses of barbiturates may he more effica- 
cious if sedation must be einjdoyecl. 

All patients who have receiv'd multiple 
transfusions must he carcl’ully waitched for 
continued bleeding at the end of the ojX’rativc 
period, or in the postoperati\’e jx'riocl. The 
cause for such oozing is not complctelv under- 
stood. At present, the treatment normally em- 
ployed for such excessive oozing is the admin- 
istration of freshly drawn blood, or fresh frozen 
plasma. 

Much investigative work concerning shock 
is in progress. Any resume ol the current think- 
ing on the subject may well be outdated in a 
matter of months. 

READING REFERENCiiS 

Symposium on the Shock Syndrome. Ann. New York 
Acad. Sc, 55:345, 1952. 

Symposium on Shock. Army Medical Service Graduate 
School, 1951. 



5 


Principles of Pre- and Postoperative 

Care 

PREOPERATIVE, OPERATIVE AND POSTOPERATIVE 

CARE 

By RICHARD L. VARCO, M.D. 

Richard Lynn Varco, horn in Montana^ was educated at the University of Minnesota, 
and has had teaching and research experience in the Departments of Medicine, Physi- 
ology and Surgery in his training for surgery. He is now Professor of Surgery. In their 
investigative work, he and his collaborators exemplify the rewards to the patient which 
can result from practical application of the principles of the basic sciences to the art 
of the practice of surgery. 


Medical students often freely concede that 
the numerous, at times 'intricate, and perhaps 
tedious problems of preoperative and postopera- 
tive care fail to capture their interest quite as 
readily as do the more glamorous operative 
aspects of surgical practice. With experience, 
however, they are more ready to acknowledge 
that any efforts devoted to these less dramatic 
activities' are necessary to ensure a smooth or 
even successful convalescence. During recent 
years, the steady decline in the mortality and 
morbidity rates for surgical procedures stems 
in a fair measure from a wider recognition and 
practice of the principles of preoperative and 
postoperative care. Besides making any pro- 
cedure safer, this knowledge has eased the 
restrictions against operating on both elderly 
persons and the very young. Now, these pa- 
tients need rarely be refused the most formid- 
able type of operation solely because of age. 
Finally, through careful attention to these 
same details, it has become possible to broaden 
generously, without incurring an unreasonable 
hazard, the magnitude of surgery undertaken 


to meet the most complex therapeutic prob- 
lems. 

PREOPERATIYE CARE 

An orderly plan for questioning and exam- 
ining each surgical patient, except in emergen - 
cies,‘ is of fundamental importance. The stu- 
dent should learn to, listen well in order to 
secure the maximum of information from the 
patient. To avoid the omission of pertinent 
details, many institutions provide outline 
guides for the history-taking and the physical 
examination. The student’s methodical use of 
these forms is recommended until repetition 
and experience have stamped the essentials 
into his memory. Such discipline will con- 
tribute to the avoidance of grave and occa- 
sionally embarrassing oversights. A lengthy 
transcription of the history and a detailed 
description of the physical findings may try 
the students patience, until he realizes how 
that background becomes an important pre- 
amble to the intelligent care of each individual. 
After the patient’s historical and physical data 


Page 109 



110 Chapter 5. Principles of Pre- and Postoperative Care 


have been recorded, the following laboratory 
tests and roentgen-ray studies should regularly 
be obtained: 

Amlysjs of the urine: specific gravity, ^Ib^^ 
min, sugar, ac"etone or diacetic acid and micro- 
scopic sediment. • 

Blood study: hernoglobin estimation and/or 
red blood cell count, total white blood cell and 
differential" counts. Although sometimes omit- 
ted routinely, measurements of the bleeding 
and clotting times and typing of the patient’s 
blood are wise precautionary measures. 

Chest roentgenogram^ or photo flumogram. 

A carefuTappraisal of the history, physical 
findings and these laboratory data will serve 
as a guide to initiating the care for the usual 
patient. In many surgical subjects, it will 
represent an adequate preoperative work-up. 
Yet, in others there may be recognized the 
pathologico-physiologic conditions of starva- 
tion, dehydration, and anemia as well as the 
coexistence of a concomitant affliction such as 
diabetes or cardiovascular, renal or pulmonary 
disease. The situation may prove to be so 
intricate that a variety of complex laboratory, 
roentgenographic and diagnostic procedures 
are required. These needs will have to be de- 
cided upon, on an individual patient basis 
and sometimes require consultation to deter- 
mine the best use of the more complicated and 
costly diagnostic tools. 

Nutritional Management. The person who 
has been eating well and has lost little or no 
weight will require no special preoperative die- 
tary management. On the contrary, the patient 
who has sustained a recent serious weight loss 
and is malnourished presents a substandard 
operative risk. A major operation performed 
on this individual will carry increased mortality 
and morbidity rates. This has been repeatedly 
demonstrated by many surgeons from sad per- 
sonal experience. Therefore, surgical benefits 
have not infrequently been denied the mal- 
nourished patient. If he is accepted without 
special nutritional rehabilitation after appraisal 
and acknowledgment of the increased hazards, 
the operative manipulations are often poorly 
tolerated. The patient may react unfavorably 
from the outset, with an instability of blood 
pressure out of proportion to the actual blood 
loss. Numerous transfusions at the time of 
operation seem to provide only transient sup- 
port to the blood pressure. The convalescence 
is slower than is normal and is disturbed by a 


greater incidence of complications such as ileus, 
impaired wound healing and disruptions or 
stomal obstruction. The patient who is ener- 
vated by starvation lacks the I'itality to over- 
come such hazards and the surgical risks are 
greater than for the properly nourished sub- 
ject. 

Starvation, when severe, produces grave bod- 
ily derangements and is characteri'/ed by 
hepatic dysfunction, impaired wound healing, 
hypoproteinemia and a contracted blood vol- 
ume. These pathologic changes arc reversible 
when appropriate dietary management is pos- 
sible. The return to normal is slow and it 
requires many days or weeks of tlierapy to 
achieve recognizable nutritional restitution. 
Sudden and dramatic benefits are rarely ob- 
tained. The problem is complicated by a dearth 
of simple, accurate methods for measuring 
precisely the effects of starvation. I.akewise, 
there is no test to indicate the quantity of 
nourishment required for the re-cstahlishment 
of health. Fortunately, the restoration of the 
bodily economy to less than ideal performance 
suffices. After an adequate but jxirtial nutri- 
tional restoration of the patient, the surgeon 
can operate and anticipate a convalescence 
as free from complications as in a standard-risk 
subject. 

During periods of relative starvation, the 
patient becomes autocannibalistic. His energy 
requirements are derived principally from body 
protein or fat, and he subsists on a low caloric, 
low protein, high fat diet. Logic suggests, and 
experience confirms, the characteristics of a 
diet most likely to correct the effects of such 
starvation. In the laboratory and from clinical 
studies, it has been found that this diet should 
be rich in protein and carbohydrate, high in 
calories and low in fat content. Of these con- 
stituents, protein plays a leading role. The 
principal sources of protein in natural foods 
are meat, fish, eggs, certain dairy products and 
cereals. Yet in each of these, the protein con- 
tributes but a small fraction of the total bulk. 
It becomes necessary, therefore, to give an 
enormous quantity of food when a large pro- 
tein intake is desired. To achieve a protein 
intake of 300 gm. when beef is the source, a 
pot roast or steak weighing about 3 pounds 
would have to be eaten. This gargantuan feat 
is usually beyond the capacity of the patient 
who is weakened and anorexic from prolonged 
starvation. Reasonable quantities of tastily pre- 
pared and attractively served foods will foster 



Ill 


Preoperative, Operative and Postoperative Care 


the consumption of a high protein diet. Cer- 
tainly, every patient who can obtain the neces- 
sary quota from the available hospital fare 
should be encouraged to do so. Physical factors 
will, however, tend to limit the accomplish- 
ments possible by this means. In such cases, 
liquid feedings will provide a useful means of 
supplementing the protein intake. Milk is an 
excellent vehicle for such mixtures and will 
hold substantial quantities of protein concen- 
trate and carbohydrate. A wide variety of pro- 
tein concentrates or digests are available. Skim 
milk powder, about 38 per cent protein, is 
among these. It is inexpensive, is widely avail- 
able, stores well in bulk form, and can be 
disguised to palatability in a variety of concoc- 
tions. Its proteins are complete and possess a 
better than average capacity to induce plasma 
protein regeneration. 

The use of a liquid diet to supplement the 
hospital fare, or as the sole source of calories, 
finds valuable and frequent application in pa- 
tients with lesions of the esophagus, stomach 
and duodenum. This is particularly true when 
mild to severe degrees of obstruction compli- 
cate the preoperative status. Not uncommonly, 
incomplete mastication results in greater de- 
grees of pyloric obstruction. One can lavage 
the chunks of swallowed food by means of a 
large-bore gastric tube and thereafter a satis- 
factory amount of liquid will often pass the 
stenotic area each twenty-four hours. Several 
diets have been tried at the University of 
Minnesota Hospitals, but the following, with 
minor variations, has been the most adaptable: 


adapted from intravenous flasks with depend- 
ent air^^ts. This permits the entering bub- 
bles, ^s they rise, to agitate the mixture gently, 
reducing the tendency towards sedimentation 
and plugging. A Murphy drip apparatus is in- 
serted into the connecting tubing, and the 
visible rate of flow can be regulated by the 
patient using a thumb screw attachment. 

For those who prefer to drink the mixture, 
it has a taste similar to that of an eggnog. The 
flavor can be readily modified with chocolate, 
vanilla or other obvious choices. This diet can 
be used by outpatients also. Simple mimeo- 
graphed directions about its preparation, the 
volume to be consumed daily, and the refriger- 
ation requirements should be given to the out- 
patient together with instructions covering the 
importance of its prescribed usage. Whenever 
this liquid diet constitutes the sole source of 
food for the patient, he is urged to take daily, 
if possible, about 5000 calories, i.e., 3 liters. 
When it is used as a supplement to ordinary 
fare, the consumption of 1 liter may suffice. 
Diarrhea will sporadically occur in persons re- 
ceiving this diet, hut it can largely be avoided 
by keeping unused portions of the prepared 
batch under refrigeration and by the use of 
clean or sterilized dispensing equipment. If it 
occurs despite these precautions, small doses 
of paregoric and/or Amphojel will ordinarily 
correct the situation. Patients with regional 
enteritis, or ulcerative colitis, are rather con- 
sistent exceptions to this rule and should be 
tested with small amounts to determine their 
individual tolerance. For a hospitalized patient, 


LIQUID DIET (2446 CALORIES) 


Whole eggs, 6 
Egg whites, 2 

Skimmed milk powder, 4- oz. 
Lactose, 300 gm. (beet or cane 
sugar may be substituted) 
Skimmed milk, 1000 cc. 

Salt, 5 gm. 


This mixture passes readily through a no. 
16F nasogastric catheter. Tubes constructed of 
plastic are rather less annoying to the patient 
than are those of other material, particularly 
when they must lie in place for several days. 
This liquid diet can be dispensed through a 
drip-feeing apparatus. For this arrangement 
the best functioning containers have been 


PROTEIN FAT 

(gm.) (gm.) 

36.0 36.0 

8.0 

58.8 40.4 1.2 

300.0 

50.0 36.0 


408.8 120.4 37.2 

the use of a liquid diet with a fixed caloric 
value per cubic centimeter simplifies the calcii- 
1 ation oFlEe ’daily caTofi T intake on the b asis„. 
oFlEF^vdlumF' "Consumed. The amount is 
charted "irdng'wtbThg^tem;^ pulse and 
respiration rates, and fluid intake and output 
weight The nutritional status is thus brought 
into focus at the bedside while rounds are be- 


GARBOHYDRATES 

(gm.) 



112 Chapter 5 . Principles of Pre- and Postoperative Care 


ing held. This close contact with dietary man- 
agement through a day-to-day accounting of 
progress or loss is of fundamental importance 
for the consistently effective preoperative care 
of substandard-risk patients. 

Objective measurements of the accomplish- 
ments of this hyper-alimentation regimen are 
virtually nonexistent. Until more critical tests 
are available, the method to be presented offers 
a reasonably reliable means of calculating the 
duration of the special dietary regimen. It is 
important to find out the amount of weight 
that the patient has lost. This figure should 
regularly be available and recorded in the ad- 
mission history. Patients often do not know 
the exact amount of weight lost, but nearly 
always are able to recall a maximum weight 
determined for some time during the previous 
three to six months and this can be compared 
with the admission figure. Any loss is more 
significant if expressed as a percentage of the 
total body weight. When this value becomes 
25 per cent or more, a period of at least two 
weeks of dietary preparation is desirable. Each 
day, the patient should try to consume about 
4500 to 5000 calories. If this total is obtained 
solely from consumption of a mixed diet, the 
proportions of protein, carbohydrate and fat 
should approximate those indicated in the 
liquid diet mixture. These estimates for the 
duration and amount of augmented caloric 
intake have been tested by trial and error for 
many patients having nutritional problems and 
probably are maximal rather than minimal. 

It is important that the dietary preparation 
should take place in the preoperative phase, 
because the weight of investigative evidence 
indicates a greater retention of nitrogen from 
protein ingested during this period as compared 
with that ingested soon after operation. The 
establishment of any large nitrogen gains offers 
considerable difficulty during the catabolic 
phase which arises in the immediate postopera- 
tive period. The problem becomes even more 
awkward when the enteral route is no longer 
available because of ileus or vomiting. If the 
patient has had an adequate nutritional pre- 
operative preparation, he can usually leave the 
hospital after the same postoperative period 
which a standard-risk patient requires. A plan 
for preoperative dietary management of sub- 
standard-risk patients will result in shorter hos- 
pitalization periods than will performance of 
an early operation followed by a complicated 


convalescence or a protracted interval required 
for nutritional rehabilitation. 

In some nutritional problem patients, the 
oral route is not available (or protein and 
caloric replenishment because of alimentary 
tract obstruction. Lllcerativc or neoplastic dis- 
ease of the esophagus, stomach or duodcnuni 
is the most common cause. Ultimately, a sur- 
gical procedure of considerable magnitude may 
be required to correct the pathologic condi- 
tion. Two alernativc methods arc a\'ailable for 
this nutritional preparation. y\ jejunosiomy can 
be made and the feeding mixtures then dripped 
into the intestine at its level. In many of these 
subjects, a diarrhea, difficult to manage, devel- 
ops before the quantity of material fed daily 
reaches the required caloric value. I his diarrhea 
often fails to respond despite recourse to a wide 
variety of dietary formulas and certain of the 
patient’s limited reserves are depleted in the 
volumes of liquid stool lost. 

The other alternative is the establishment 
of a comprehensive parenteral feeding [)rograni, 
striving to attain the dual goal: meet the daily 
caloric requirements and acquire the maximum 
possible nitrogen retention. The caloric needs 
are supplied by glucose in 5 to 20 per cent 
solutions. At least 200 to 250 gm. of carbohy- 
drate daily are required to provide the body’s 
energy needs. Unless this is available, sub- 
stantial quantities, cither of body protein or of 
infused nitrogenous material, will continue to 
be catabolized for fuel. The jirovision for this 
protein-sparing action by carbohydrate is, there 
fore, an essential component of tlie ebb and 
flow of nitrogen reservoirs. To a limited extent, 
solutions for intravenous use containing fat 
emulsions may provide energy units, llieir 
best feature is the high (9) caloric value per 
gram of fat. Limiting factors are their some- 
what limited availability, relative instability 
under varied climatic conditions, and periodic 
tendency to provoke unpleasant systemic reac- 
tions. They may have particular usefulness in 
the nutritional care of severely burned patients 
requiring high caloric intakes. The other major 
control of the state of the nitrogen I)alance 
comes through the kind and the amount of the 
nitrogenous compounds administered paren- 
terally. The nitrogen-containing compounds 
available for parenteral use are pure amino 
acid mixtures, gelatin, protein hydrolysates, 
albumin, plasma and whole blood. 

Pure amino acid mixtures are still rather 



Preoperative, Operative and Postoperative Care 113 


costly, and the limited supplies are largely al- 
located to investigative work. 

Gelatin has some application to the emer- 
gency restoration of blood volume in shock 
therapy if plasma and whole blood are not im- 
mediately available. Its contribution to paren- 
teral nitrogen therapy is dubious. 

Protein hydrolysate mixtures are obtained 
from the acid or enzymatic hydrolysis of a 
variety of substrates. The resultant commercial 
preparations are widely available. Casein has 
usually furnished the source of protein in 
these digests. The hydrolysates are readily in- 
fused as 5 per cent solutions with an equal or 
lesser concentration of glucose, A rate of in- 
fusion of about 500 cc. per hour is well tol- 
erated in most cases. If the injection is much 
faster, the incidence of unpleasant systemic 
reactions (nausea and vomiting) increases. The 
total nitrogen intake from parenteral use of 
hydrolysate mixtures is, therefore, limited to a 
smaller value than when the oral route is avail- 
able. The total urinary nitrogen loss in twenty- 
four hours following the venoclysis of hy- 
drolysates and glucose is greater than after the 
feeding of equivalent amounts of skim milk 
powder. Despite these limitations of parenteral 
therapy, the hydrolysates occupy an important 
role in nitrogen replacement therapy. Through 
their agency, it is possible to retard the steady 
protein losses from starvation and allied de- 
pleting mechanisms (ulceration, sepsis and 
hemorrhage). 

The daily nitrogen intake is most sub- 
stantially augmented by repeated transfusions 
of plasma or whole blood and is not followed 
by a prompt increase in the urinary nitrogen 
losses. Blood transfusions are preferable in the 
anemic patient, to be sure. Daily infusions of 
500 to 1000 cc. of whole blood should continue 
until the hemoglobin and hematocrit values 
reach and remain in the normal range. And 
as a corollary, it can be expected that until 
the patient's blood volume has been filled up, 
successive transfusions will not bring the 
hematocrit above a normal value. For the 
poorly nourished patient, as much as 2500 cc. 
of blood may be required. These patients often 
suffer from a contracted blood volume and are 
poor operative risks until this is restored. A 
high grade correction of this hypovolemic-re- 
duced red cell mass defect is customarily re- 
alized by this plan. The associated hypopro- 
teinemia is less regularly and predictably 
restored to normal, but in all instances is 


improved. The plasma protein value can addi- 
tionally be raised by the injection of albumin; 
however, this is costly, not always available nor 
frequently necessary. After the phase of re- 
plenishment, a daily transfusion of plasma 
and/or whole blood, plus at least 3 liters of 
hydrolysate-glucose mixture, can be relied 
upon to provide the soundest possible paren- 
teral preparation. 

This type of preparation represents a more 
complicated problem. It requires the services 
of a conscientious, tactful and patient house 
officer with sufficient skill to minimize the de- 
velopment of thromboses in all the cutaneous 
veins available to and essential for a prolonged 
period of intravenous therapy. In this connec- 
tion, use of a forearm vessel away from the 
antecubital fossa avoids the distress of hyper- 
extension at that joint. It permits some latitude 
of movement without the danger of dislodging 
the needle and burying it into adjacent tissue, 
thereby causing a painful perivenous injection. 
Sterile, small-bore polyethylene tubing can be 
inserted through the lumen of a large in- 
travenous needle into the blood stream. It may 
then be fastened with a dressing and left in 
place for several days. This conduit can be 
connected to the drip apparatus and saves wear 
and tear on the patient's arm and disposition. 
At the conclusion of each day's infusion sched- 
ule, if the tubing is flushed wuth a few cubic 
centimeters of isotonic saline solution contain- 
ing heparin, and then plugged with a sterile 
phonograph needle, it remains patulous and 
ready for the next injection. When there is a 
paucity of superficial veins and considerable 
intravenous therapy is necessary, this method 
will help resolve a dilemma. A caution is of- 
fered against routine use of the saphenous 
venous system lest one thereby provoke a high 
incidence of thrombophlebitis and phle- 
bothrombosis. This vein is especially prone to 
that complication. Therapy for this group of 
patients being prepared by parenteral feeding 
should be compressed into as short a period as 
possible. This applies even to patients with 
marked weight loss, anemia, hypoproteinemia, 
edema and other stigmas of starvation. They 
are prone also to those complications unique 
to an inlying nasal tube and to regurgitation, 
plus the effects of relative postural immobiliza- 
tion during parenteral alimentation. Usually 
from seven to ten days can safely be devoted 
to achieving maximum benefits. Even less time 
may need be spent in rehabilitating nutrition- 



114 


Chapter 5. Principles of Pre- and Postoperative Care 


ally those patients who are only moderately 
malnourished but with this same type of par- 
tial, high, alimentary tract obstruction. 

Anemia and Hypoprnteinemia. Chron- 
ically ill patients regularly exhibit some degree 
of anemia and protein depletion. The total ex- 
tent of these defects is masked to a greater or 
lesser degree by contractions of the blood vol- 
ume and/or plasma volume, or protein reser- 
voirs. As a consequence of the decrease in the 
red cell mass and in the total amount of circu- 
lating plasma protein, these patients are in- 
tolerant of additional blood loss during opera- 
tion and display evidence of impaired wound 
healing and decreased resistance to infection. 
The term 'chronic shock" has been applied 
to such cases. 

The anemia and hypovolemia are readily 
corrected in most patients by a sufficient num- 
ber of whole blood transfusions given at the 
rate of 500 to 1000 cc. daily. Blood volume 
determinations, calculated for the usual weight 
prior to the current illness and rechecked after 
treatment, give a rather precise measurement 
of these requirements. Practically, this is a 
somewhat demanding technical procedure for 
routine care. Provision for multiple transfusions 
until the hemoglobin or hematocrit values are 
normal, or slightly above normal, has proved 
a reliable expedient. The lowered plasma pro- 
tein value is more difficult to correct because 
small deficits in it are in "dynamic equilibrium" 
with quantitatively much larger debits of the 
total body protein. Following massive transfu- 
sions of whole blood and/or plasma, the protein 
concentration is usually improved, and the 
total mass is increased, hut often remains below 
a normal value. Proper nutritional measures 
during this period of preparation will supply 
additional protein to bolster these depleted 
reservoirs. Whenever the oral route is available, 
the acceptance of diets high in protein, carbo- 
hydrate, and caloric content substantially com- 
plements the protein intake from transfusions. 
At least a partial restoration of these depots is 
essential to meet the aggressive protein demands 
of the healing tissues, the countless phagocytes 
maturing, and the reticuloendothelial elements 
creating immune bodies for resistance to in- 
fectious processes. 

Heart Disease. The patient with heart dis- 
ease may require an abdominal operation as 
urgently as does his healthier contemporary. 
With careful attention to certain details, the 


chances of such a patient’s undergoing an ab- 
dominal, or thoracic, operation of magnitude 
successfully can he greatly improved. y\n elec- 
Jrpcardiograirg-eardiac fluoroscopy, venoyrs-pres- 
sure determination, and vital cap acity measure- 
ment furnish worthwhile' preoperative data. 
Whether normal or grossly altered, they repre- 
sent significant base lines for comparison with 
later values. In the event of a complicated con- 
valescence, a suspicion of incipient trouble 
gains greater credence and is easier to verify 
with such information available. When frank 
heart failure is detectable on the basis of pul- 
monary congestion or effusion, or h\’ ascites or 
peripheral edema, then j)reoperati\'e medical 
advice and management are advisable. Mean- 
while, it is best to initiate a jn'ogram of salt 
restriction, combined with the u.sc of diuretics, 
unless contraindicated by renal factors. /Vnoxia, 
hypercapnea, shock, and ovcrhyclration with 
an excessive salt intake arc the most common 
surgically induced mechanisms functioning as 
precipitants of cardiac disaster. Although cer- 
tain of these are customarily the resj^onsibility 
of the anesthesiologist, it is regrettable if they 
serve as debating points to widen a breach, 
the nonexistence of which wmuld profit all. 
The most knowing and effective anesthesi- 
ologists are surely those persons functioning 
surgically, co-operatively, simultaneously, as co- 
equal members of the team at work 'in a par- 
ticular area but with a dedicated interest in 
the whole of the patient. 

Shock. Shock readily contributes to the 
precipitation of a cardiac crisis in an already dis- 
eased organ. When the surgeon has been 
warned by the admission history, the physical 
examination, and special tests, he can take 
certain precautions. These relate particularly 
to provision for accurate volumetric transfusion 
to replace measured blood losses during the 
operation. Replacement of blood is more pre- 
cise if the blood-stained sponges are weighed 
during the operation. There can be no escape 
from the recurrently demonstrated fact that 
the prevention of shock is far more successful 
than its treatment. 

Overhydration. The indiscriminate use of 
sodium-containing parenteral fluids is capable 
of imposing a serious cardiac overload. Unless 
careful attention is focused on this issue, heart 
failure will occur in many patients with a 
low cardiac reserve. These sodium-retained ac- 
cumulations of fluid can Be fatal. As a corollary 



115 


Preoperative, Operative 

of this, it should be indicated that the abrupt 
restoration of values to “normal" levels may 
pose fatal consequences in a patient maintained 
on a low sodium diet in the control of his 
heart disease. 

Pelmonary Disease. The presence of any 
substantial amount of pulmonary disease is 
ordinarily ascertainable from the history, phys- 
ical examination and admission chest film. 
Routine preoperative measurement of the 
vitaI^^ca^eitjL.i$ desirable before every major 
operation? Any serious reduction of the vital 
capacity is particularly important if the patient 
is asthm atic, emphyse matous, or carries ad- 
vanced stages of pulmonbry b^pSensiorunTI^ 
use of the one second vital capacity is an even 
more valuable index of functional capacity in 
these crippled people. It should be at least 
80 per cent of the total expiratory volume. A 
simple, but functionally useful, test of respira- 
tory reserve is to walk up a few flights of stairs 
with a patient and note his tolerance to this 
amount of physical activity. The prophylactic 
use of penicillin for several days preoperatively 
in these patients and in those with related dis- 
orders is an inexpensive precaution and appears 
to lower the incidence of postoperative pul- 
monary complications from atelectasis and 
pneumonia. 

Vitamins. The chronically malnourished 
patient may have either subclinical or manifest 
avitaminosis. If the clinical picture or labora- 
tory tests establish the diagnosis, specific vita- 
min therapy is indicated. Whenever the oral 
route is available, it is preferable. Intravenous 
preparations are more costly and their use 
should be reserved for those patients in whom 
the enteral route is unavailable through ob- 
struction, vomiting or diarrhea. In the absence 
of a deficiency requiring specific therapy, only 
three vitamins are important in the routine 
surgical care of patients: vitamins Bi, C and 
K. 

Thiamine (vitamin Bi) participates in those 
enzyme systems which regulate carbohydrate 
metabolism and maintain normal gastroin- 
testinal activity. In any nutritional prepara- 
tion involving large quantities of carbohydrate, 
liberal amounts (10 to 20 mg. daily) are ad- 
vised. Intravenous infusions of glucose rapidly 
deplete the existing stores of vitamin Bi. 
Any latent deficiency is thus promptly 
made worse. Carbohydrate metabolism itself is 
impaired, further hampering the nutritional re- 
habilitation. Sulfasuxidine given orally will 


and Postoperative Care 

increase the thiamine requirements in the diet. 
When excess quantities of thiamine are pro- 
vided, they are either lost in the urine, or 
stored, and appear to cause no deleterious 
effects. The preferred route for administration 
is the oral one, because of the slower absorption 
and hence more prolonged systemic action. If 
thiamine is given intravenously with glucose 
solutions, the daily dosage should be kept di- 
vided, lest an unnecessary excess of the vitamin 
be largely lost by diuresis. 

The contribution of vitaviin C to wound 
healing is clearly established. A low tissue 
\'itamin C content is correlated with an in- 
creased incidence of wound disruption. De- 
ficiencies can often be suspected from a history 
of a dietary intake deficient in fruit or raw 
vegetables, occurring in a person with an ulcera- 
tive lesion of the gastrointestinal tract. The 
plasma ascorbic acid content can be readily 
measured. Vitamin C deficiencies result from 
an inadequate intake, faulty intestinal absorp- 
tion, or an excess loss from, or sequestration by, 
the tissues. In the instance of burns, or large 
ulcerating areas, this mechanism can increase 
the daily requirements to at least 1 gm. Tissue 
saturation is easily attained by means of oral 
preparations; parenteral solutions are available 
if the oral route cannot be used. Any super- 
fluous amount spills over and is lost in the 
urine, causing no harmful reaction. A daily dose 
of 500 mg. is ample for most contingencies met 
with in the preparation of surgical patients. 

A prolonged deficiency of vitamin K, a fat- 
soluble vitamin, disrupts the clotting mecha- 
nism producing a hemorrhagic diathesis. A 
continued lack of adequate amounts of vita- 
min K prevents the formation of prothrombin 
by the liver. Hypoprothrombinemia interferes 
with blood clotting at the thrombin-conversion 
stage. The common precursor of vitamin K de- 
ficiency is any mechanism which prevents its 
formation in, and absorption from, the intes- 
tinal tract, as in some type of biliary obstruc- 
tion, or from an external biliary fistula. With- 
out the emulsifying action of bile, this naturally 
fat-soluble vitamin cannot be absorbed. Pro- 
longed oral use of sulfonamides and strepto- 
mycin will reduce the bacterial flora of the in- 
testine and may inhibit vitamin K synthesis 
sufficiently to cause serious hypoprothrom- 
binemia. Vitamin K should be given paren- 
terally in such subjects. Hypoprothrombinemia 
occurs also in association with severe hepatic 
disease, and if the plasma prothrombin value i,s 



116 


Chapter 5. Principles of Pre- and Postoperative Care 


not correctable to around 80 per cent of the 
normal with therapeutic amounts of vitamin 
K given parcnlerally, this test becomes of grave 
prognostic significance. Essential hypopro- 
thrombinemia, a rare disease and conceivably 
a congenital metabolic defect, is an exception 
since other evidence of hepatic disease may be 
lacking in these cases. For patients with hypo- 
prothrombinemia which is not benefited by 
\dtamin K therapy, massive transfusions of 
freshly drawn plasma or whole blood will 
temporarily elevate the plasma prothrombin 
content, and the bleeding tendency can usu- 
ally be controlled sufficiently to permit any 
essential operation. In any emergency, minor 
defects of circulating prothrombin can be so 
managed. With the availability of vitamin 
oxide for intravenous use, there is usually a 
more prompt restoration of prothrombin con- 
tent to circulating blood. 

All patients suspected of being hypopro- 
thrombinemic should be tested with regard to 
the prothrombin time. The result is usually 
checked by determining the plasma prothrom- 
bin time of a normal patient's plasma, used as a 
control for the materials and methods. Also, this 
function can be charted as the percentage of 
normal clotting activity: the normal patients 
plasma prothrombin time divided by the pa- 
tient’s plasma prothrombin time multiplied by 
100. The prothrombin percentage can be cal- 
culated from a curve derived by plotting pro- 
thromhin times against serial dilutions of nor- 
mal plasma. The curve is accurate as a standard 
only when the same potency of thromboplastin 
as was used in obtaining the curve is used for 
testing the unknowns. Bleeding is unlikely to 
occur unless the patient's prothrombin time is 
at least twice that of the control, or until the 
percentage of activity reaches the lower 50 
percentiles. In most instances of vitamin K de- 
ficiency, considerable response is seen within 
twenty-four to thirty-six hours after therapy is 
started. A daily dose of 5 to 10 mg. customarily... 
will suffice, for this purpose. Quantities of the 
vitamin in excess are well tolerated and appar- 
ently do no harm. Water-soluble preparations 
for parenteral use are ■■ available whenever 
medication cannot fie' given orally. 

Final Preparation. In the afternoon before 
a major operation scheduled to occur on the 
following morning, written orders are usually 
posted covering the following: (Ij) Skin prep-/ 
aration. The., directions specify the extent of^ 
the site to be shaved and washed thoroughly 


with soap and water or, better )'et, with one 
of the new bactericidaQdetcrg^its. (2) y\ gen- 
tle-action enemaZSaline solution ,or U\p water, 
to cleanse the lovyer bowel. (^81 /\ light but am- 
ple evening meal. (4) Voiding or catheteriza- 
rioiF'BeForc thtrpaticnt isfiaken to the operating 
room. (5j Scd cttion, adequate to allay appre- 
hension and to give the patient a night’s re- 
pose. (6) Omission of all food and oral fluids 
after midnight. (7) Drawing of blood for cross- 
matching and (Inal laboratorv' tests (.prothrom- 
bin, bleeding and clotting time). (8) Prc-ancs- 
thetic medication. (9) Insertion of a nine-holed 
gastric tube under certain circumstances. The 
use of this last-mentioned 'teclinicfiic starting 
the evening before the operation permits the 
surgeon to work with a collapsed bowed, and 
facilitates any intra-abdominal procedure. 

For operations which are likelv to he started 
late, it is wise to begin meeting the fluid re- 
quirements for the day with an intravenous 
injection, 1000 to 1500 cc. of a 5 to 10 per 
cent solution of glucose with the daily vitamin 
requirements, slowly given. In addition to ful- 
filling some of the body’s energy reciuirements, 
any tendency to preoperative dehydration is 
controlled. It is to be noted that unless the 
patient voids, or is cathctcri/.ed, before going 
to the operating room, serious vesical overdis- 
tention may develop postoj)erativcly before the 
patient can void voluntarily or bo catheterized. 

A liberal measure (2 to 3 ounces) of mineral 
oil by mouth the night before an operation and 
repeated when the nasal tube is removed will 
minimize the distress of passing the first post- 
operative, and often inspissated, stool. At a time 
when straining is painful, such forethought 
will he appreciated by the convalescent. 

For operations upon the stomach and 
esophagus in the par- 

ticular care should be given to removing food 
debris, which is a rich medium for pathogenic 
bacteria, particularly when associated with 
achlorhydria. Re peated wash ings jwifh a large- 
bore tube are required upon thcs"c’ occasions,, 
to remove this partially digested material This 
precaution effectively decreases the potential 
for regurgitation and aspiration of material 
seething with pathogens which, if they come 
to lodge in the bronchioles, are certain to pro- 
voke a severe pneumonitis. The use of neo- 
mycin orally will effectively reduce the colony 
strength of the gastric bacterial flora also. 

In patients having incomplete or potential 
obstruction of the colon, it is highly desirable 



117 


Preoperative, Operative 

to prevent this from becoming complete. Other- 
wise, a decompressive operation becomes neces- 
sary in addition to the resection procedure. The 
diet should be selected, therefore, with an eye 
to its low residual content. The bulk and con- 
sistency of the stool can be effecti\’ely reduced 
also by giving Sulfathalidine, Sulfasuxidine, 
and/or neomycin by mouth. Mineral oil given 
orally several times daily will counteract a 
tendency to impaction above the lesion. If these 
measures prove ineffectual and some degree of 
obstruction persists though still incomplete, 
the temporary use of continuous gastric suc- 
tion may still obviate the necessity of a colos- 
tomy. Any final nutritional preparation can 
then be accomplished through parenteral 
alimentation. 

OPERATIVE CARE 

During an operation, attention should con- 
tinue to be focused on the same physiologic 
factors which were of concern preoperatively, 
i.e., any hemoglobin, electrolyte and fluid de- 
ficiencies, together with attention to cardio- 
renal and pulmonary dysfunction. The employ- 
ment of a scale for accurately weighing the 
blood loss during the operation is of value. By 
the use of dry fluffs and packs to collect the 
blood throughout the dissection, a close meas- 
urement of the sanguinary loss can be re- 
corded. Exposed viscera are, to be sure, pro- 
tected against dehydration by packs moistened 
with saline solution. Otherwise, various types 
and sizes of dry sponges are employed and 
when they become blood stained and are 
counted'^by a circulating nurse, their gain in 
weight can be written down. This gravimetric 
determination of the blood loss compares re- 
liably with colorimetric mensurations. Such a 
procedure is advantageous because the amount 
of blood lost is known at once, inasmuch as a 
running tabulation is thus kept by the at- 
tendant, The wisdom of shock prevention ver- 
sus shock therapy is acknowledged and demon- 
strated by providing the patient with blood in 
an amount slightly in excess of this volume 
being lost. Furthermore, a surgeon who is 
regularly confronted with blood losses larger, 
for comparable procedures, than those of his 
colleagues can profitably speculate about his 
regard for hemostasis. For small children (up 
to 20 kg. in weight) the use of a scale in the 
operating room is also highly accurate, in yet 
another fashion, for measuring the total blood 
/e.'ss realized during an operation. Once the 


and Postoperative Care 

child has been precisely balanced just before 
the operation begins, the only change at the 
termination of the surgical procedure must be 
from blood loss and the specimen removed. 
When carefully done this technique gives 
values which should he \^erY close to accurate 
ones. 

The fluid losses through sweating during a 
prolonged operation can be considerable in an 
adult if the weather is hot and the operating 
room is not air conditioned. These fluid re- 
quirements should be met by replacement of 
water and electrolytes during the operation. 
Adequate hydration thus maintained will re- 
duce the number of mechanisms provoking 
postope^ati^'e oliguria. The routine inclusion 
of an intrat^enous set-up among the operating 
room facilities is, therefore, recommended for 
all major procedures. This equipment can be 
so adapted as to permit the ready infusion of a 
variety of solutions (glucose in distilled water, 
isotonic saline solution, and anesthetic mix 
tures and plasma) and should include a can- 
nula, or needle, suitable for the rapid trans- 
fusion of whole blood. Either the antecubital 
or the saphenous vein may be used, but the 
needle must be shielded from dislodgment dur- 
ing operative manipulations. 

For surgical procedures of any duration, 
some protection should he provided for the 
patient’s bony prominences. A sponge rubber 
or air mattress is best, but air-filled rings will 
suffice. A scrawny individual, in particular, 
can readily acquire areas of pressure necrosis 
unless protected. The unrelieved weight of 
the patient, the drapes, sundry equipment and 
a tired, leaning assistant have undoubtedly 
caused some of the bedsores customarily 
ascribed to negligent nursing care. 

Avoidance of anoxia is largely in the prov- 
ince of the anesthetist. It is the anesthetist’s 
obligation to insure an open airway at all times, 
from the moment of induction, through the re- 
covery of consciousness. Having developed a 
patent aiiway, the anesthetist’s next commit- 
ment is to provide for adequate pulmonary ven- 
tilation with an oxygen-rich mixture. When- 
ever the patient fails to, or cannot, respire 
deeply enough, the prevention of anoxia is 
incumbent on the anesthetist. Far more in- 
sidious than anoxia, and at least as detrimental 
to the patient’s welfare, is hypercapiiea. The 
gradual accumulation of significant volumes of 
carbon dioxide in the anesthetized patient’s 
blood, due to inadequate ventilation, produces 



118 


Chapter 5. Principles of Pre- and Postoperative Care 


profound metabolic consequences when al- 
loweied to persist any substantial period of time. 
This treacherous situation has few overt mani- 
festations likely to alert the anesthesiologist. 
Direct measurements of pH on the circulating 
arterial blood, or analyses of the expired gas, 
are revealing of the problem s magnitude. Other 
than in those institutions actively studying 
some aspect of ventilatory problems, however, 
carbon dioxide analysers are not routinely used 
by anesthetists. In the absence of such pre- 
cautionary devices, the only protection against 
hypercarbia is an unflagging attention to effec- 
tive manual or mechanical ventilation. A failure 
to recognize the pile-up of carbon dioxide, until 
this accumulation is able to produce a severe 
acidosis, may well be an initiating factor 
capable of triggering abnormal vagal reflexes 
and cardiac standstill. 

POSTOPERATIVE CARE 

The unconscious or semicomatose patient 
should be returned from the operating room 
with the head lower than the feet. A cart 
designed to be elevated at one ,end should be 
used. As a substitute procedure, the patient 
lies fiat on his side with the thighs and knees 
flexed to provide for rotational stability. The 
head then lolls dependently from the shoulder 
draining away any secretions. Whatever the 
position or method of transport, a clear airway 
is the first consideration, and a periodic cTeck 
should be made while the patien^1rl!rlrtoutB^ 
from the operating room to his bed. The prin- 
cipal object of the head-down, or the alterna- 
tive, position is to jind 

a_S 2 iratiorL^aliva or gastrointestinal contents 
VhiJiracciimulate in the tracheobronchial tree 
are a major cause of postoperative atelectasis, 
pneumonitis, and pneunaonia. An'^^^^eedve 
prophylaxis against thiT occurrence is the 
routine use of a nasogastric tube, and siphon- 
age during the^op^eration. This arrangement 
will also avertnie development of disten- 
tion secondary to the anesthetists pumping 
gas into the intestinal tract during forceful 
ventilation of the patient by means of a face 
mask. 

The use of a recovery ward in proximity to 
the operating room represents a current trend 
which has already earned approval at many in- 
stitutions. When this very helpful arrangement 
exists, then all anesthetized patients are best 
kept in the recovery ward for immediate post- 
operative care. This grouping makes their rou- 


tine care more cfiicieiit. The management of 
postoperative emergencies is likewise improved. 
There arc fewer persons to wlioin one must 
delegate the responsibility lor the patient’s care 
during the crucial first postopcratiiu hour or 
so, and the personnel working in this environ- 
ment rapidly gains exjx'ricncc in the rcc'ogni- 
tion of most types of early appearing compHca 
tions. Intelligent and alert heclsiclc nursing by 
someone well oriented in such problems is es- 
sential to the establishment of a smooth con- 
valescence. Oxygen therapy ec|uipment, trache- 
otomy trays, shock frames, transfusion appara- 
tus, motor-driven suction and other rcsuscita- 
tive equipment can be kept on hand lor prompt 
use. This well-trained group of nurses and 
doctors staffing a recovery ward can demon- 
strate to the finest their team work in the 
management of an individual wdth cardiac ar- 
rest. One such episode smoothly, expeditiously 
dealt with will cause any reasoning onlooker to 
concede the need for, and wisdom of, this 
group’s availability. 

Cardiac Arrest and Resiiscitative Measures, 

The term, ‘cardiac arrest,” is meant to include 
all forms of cardiac standstill in asystole or ven- 
tricular fibrillation wherein the heart is no 
longer able to propel a volume of blood through 
the circulatory system sufficient to produce a 
detectable blood pressure. With cither cardiac 
standstill, or the incflectual motions of \’cn- 
tricular fibrillation, no more than a lew min- 
utes must be allowed to intervene before the 
circulation is restored, if death or irreparable 
damage to the brain is to be prevented. This 
is as emergent a situation as can confront any 
doctor and must be handled decisively, 
promptly, and effectively, in order to provide 
the patient with the best opportunity for re- 
versing this catastrophe. The cells of cerebra- 
tion are particularly vulnerable to the metabolic 
consequences of the circulatory stagnation asso- 
ciated with cardiac arrest. After an interval 
of no more than five minutes, their destruction 
progresses rapidly and so, even though other 
organ systems may ultimately be restored, in- 
cluding the restoration of cardiac activity, the 
individual may have been made decerebrate 
during this period of stasis of cerebral blood 
flow. There arc many methods of ])reventing 
this grave complication, but it is to be empha- 
sized that a definite number of such instances 
can clearly be identified as arising from im- 
proper anesthetic techniques with particular 
reference to the management of high levels of 



119 


Preoperative, Operative 

carbon dioxide accumulation in the blood dur- 
ing the anesthetic interval. 

It is crucial to the success of these resuscita- 
tive measures that provisions have been made 
in advance for handling this situation—firstly, 
as far as the equipment is required, and, sec- 
ondly, in that the principles involved in sur- 
gical technique be clearly understood. An air- 
way must be promptly established and main- 
tained either by a tight-fitting mask or through 
an endotracheal tube. This arrangement must 
permit someone periodically to ventilate vigor- 
ously the lung after this organ collapses follow- 
ing the opening of the chest. An oxygen tank 
and valve system are essential to deliver the 
oxygen in as high concentrations as possible. 
Instruments with which to open the chest 
widely must be at hand and instantly available. 

A prolonged search for mask, oxygen tank, sur- 
gical instruments and related paraphernalia 
makes the grim outlook, at best, a hopeless 
cause. 

All but those individuals experienced in 
handling this complication, or those naturally 
intrepid, will inevitably have major qualms 
about assuming the required role of opening 
the chest when suddenly faced with the need 
of managing a patient considered to have 
cardiac standstill. At this moment of decision, 
there can be no justification for delay induced 
by debate or procrastination while seeking a 
superior to accept the grave responsibility. And 
precisely because the need must often be met 
by an intern or young house officer, it seems 
pertinent to provide at least this background 
of advice about what must be done. An in- 
decisive attitude will inevitably prejudice the 
outcome or even preclude any hope for success. 
Even an unduly long interval, while the doctor 
is seeking conscientiously with his stethoscope 
to be sure of a distant heart beat, may jeop- 
ardize that patient’s slim chance. Unless one 
would forfeit the patient’s life by further in- 
decision, this diagnosis must be either promptly 
confirmed or disproved. When in doubt the 
best method of settling the issue often is to 
start an incision over the region of the fifth 
intercostal space, and if this cut fails to bleed 
in the usual vigorous fashion which any wound 
should, then the operator can proceed with 
reassurance that that patient does, indeed, have 
cardiac arrest. In addition to having the ad- 
vantage of decreasing the interval left to con- 
jecture or speculation, there are the therapeutic 
advantages of settling this quandary. Additional 


and Postoperative Care 

moments may unfortunately be lost in a fruit- 
less search for sterile instruments and anti- 
septics to apply to the skin before making the 
incision. While certainly desirable, such prep- 
arations are rarely av^ailable. Thanks to man s 
native resistance and the protection provided 
by the antibiotics, one can rely on the use of 
a clean, but not aseptic, technique, This will 
usually prove a wiser choice than blind in- 
sistence on absolute listerian principles. When, 
during the course of subsequent steps, it be- 
comes feasible to shift to sterile instruments and 
equipment, this should, of course, be carried 
out. 

Once the chest has been opened and the 
heart exposed, the overlying pericardium should 
be incised so as to avoid cutting the phrenic 
nerve. After the sac covering the heart has 
been widely incised, the hand can then be in- 
troduced and cardiac massage instituted. The 
rate of this massage is important and should be 
adequate to provide a detectable pulse to the 
palpatory finger at the wrist or over the carotid 
artery. Increased cardiac filling is usually ob- 
tainable by placing the patient in a slight 
Trendelenburg position. Once an adequate air- 
way capable of permitting effective ventilation 
has been achieved, and after the establishment 
of a modest circulatory pressure by efficient 
cardiac kneading, then the next steps designed 
to retrieve this situation can be managed in a 
more leisurely fashion. The utter essentiality 
for planned, coordinated, prompt action to 
achieve these two primary objectives, however, 
is to be emphasized. These can only come when 
considerable forethought has been given to 
the management of this recurring problem by 
those responsible individuals in any post-anes- 
thesia recovery room and on the surgical service. 
The opportunities for practicing such steps on 
the medical wards axe in existence, but they 
are even less likely to be carried out because 
of an over-all unfamiliarity with procedural 
details. 

In those instances of cardiac standstill when 
the heart fails to recapture a normal beat after 
a few minutes of vigorous massage, despite the 
restoration of a pinker color to the myocardial 
tissues, together with an exhibition of the 
body’s capacity to bleed, and the detection of a 
palpable peripheral pulse by an associate or a 
nurse, then the intraventricular injection of 
epinephrine which can be massaged into the 
coronary circulation may prove ejffective. The 
volume of the drug reaching- the myocardium 



120 


Chapter 5. Principles of Pre- and Postoperative Care 


can be increased relatively, and the cerebral 
Row augmented, by temporarily compressing 
the dorsal aorta in the chest against the ver- 
tebral body with one finger while the other 
hand massages the heart. Should this initial 
dose prove inadequate to arouse a forcetul beat, 
then larger amounts should be introduced. Oc- 
casionally, the intraventricular injection of a 
10 per cent solution of calcium chloride, which 
can be similarly massaged into the myocardium 
via the coronary circulation, will prove capable 
of initiating and sustaining good cardiac activ- 
ity. The use of an extra-corporeal electrical 
cardiac pacemaker can prove lifesaving by 
supplying an impulse of strength adequate to 
initiate stronger contractile heart beats. On 
the other hand, ventricular fibrillation may be 
the initial presenting complex when the peri- 
cardium is opened. There need be no great 
haste at reconverting this vermiform, inefficient, 
activity to a normal thrust, for a far more im- 
portant objective is to restore, by manual mas- 
sage, an effective flow during those crucial first 
minutes while the patient is simultaneously 
being well ventilated. Moreover, in certain in- 
stances, fibrillation handled by massage, while 
good ventilation with 100 per cent oxygen is 
maintained, will spontaneously revert to a nor- 
mal rhythm and the heart restore itself to use- 
ful activity. On the other hand, efforts designed 
to try and defibrillate a cyanotic, dilated, heart 
will uniformly prove in vain and precious mo- 
ments as well will have been lost. After the 
cardiac tone has been restored, and good 
oxygenation is apparent in the myocardium as a 
consequence of the ventilation and the cardiac 
massage, if the fibrillation still persists, then 
electrical defibrillation is more likely to succeed. 
This technique requires the use of an instru- 
ment capable of delivering, ideally for brief 
periods of time (0.1 to 0.5 second), 110 to 250 
volts of current through the broad contacts of 
paddle-shaped electrodes applied firmly to op- 
posite sides of the heart. In order to prevent 
electroshock reaching the individual manipulat- 
ing the handles of this dcfibrillating instru- 
ment, it is vital that the individual wear rubber 
gloves free of any holes and preferably that 
the current arrive at the electroshock point 
from a specially designed instrument carrying 
an isolation transformer. The transformer pre- 
vents grounding through the operator from 
contact with a single electrode. Compact units 
are noW commercially available and should be 
looked upon as essential instruments in the 


equipnrent of busy, modern, hospital operating 
rooms, posl-ancsthcsia reco\cr}' areas and 
handily available to the surgical eornalesccnt 
floors. In the bcttcr-niadc instruint'nts, it is 
])Ossible to set rather precisely the duiaitiun of 
timing of this electrical discharge and thereby 
minimize the total amount ol heat dehhered to 
the already damaged heart. Since lower v'oltage 
levels might prove incapable ol eoiu’crting the 
heart to a regular rhythm, it is nect'ssary that 
the instrumcjit at hand be capable of discharg- 
ing up to 250 volts if required. Other than the 
visual evidence of the conversion of cardiac 
fibrillation to a regular rhylbni, or to cardiac 
standstill (subsccjucntlv to be reslorccl to a 
normal beat by massage), one can deduce also 
that the total shock delivered is acleciiiale when 
there is a convulsive mowmient on the part 
of the patient during this apj^lieation of elec- 
tricity. 

if the heart remains .somewhat llabby, and 
only partially cajxtble of ventricular emptying 
following the restoration of a regular heat, then 
it should be assisted by well-timed mas.sage at 
the height of the systole, or by recourse to the 
pacemaker instrument. Also, the heart may de- 
rive appreciable benefit from tlie judicious u.se 
of dilute solutions ol epinephrine introduced in- 
to the blood perl using the myocardium, Con- 
tinued observation of the carditic behavior is 
indicated for at least a half hour after the 
condition has improved and while the gcaieral 
situation is being tidied up. This intervitl can 
be spent in acquiring sterilized instruments 
and drapes to replace the j)artially contaminated 
equipment used on an emergency !>as{s. If, 
alter this interlude, the systemic pressure is a 
reasonable approximation of the patient’s nor- 
mal value, assuring a respectable coronary flow, 
the pericardium may be closed loosely, with 
one or two sutures, in order to prev^ent pro- 
lapse of the heart into the pleural s])ace. Tubes 
should be introduced into the thorax wltich will 
effectively drain away any postoperative pleural 
accumulation of plasma and blood. T’hey also 
manage any incidental air leak occasional by 
the rapidly executed thoracotomy. If con- 
tamination of the pleural space has been real, 
this area may be washed liberally with sterile 
solutions in order to dilute the aggregate of 
organisms and flush out any extraneous clots 
capable of serving as a focus for subsequent 
infection. The thoracotomy closure may he com- 
pleted in any standard fashion. 

When adequate additional assistance he- 



Preoperative, Operative and Postoperative Care 


comes available at any stage of this rapidly' 
moving sequence of events, someone should 
be delegated the responsibility of placing a 
wide-bore cannula of metal or polythene into 
a peripheral vein of adequate diameter. 
The availability of this route for the infusion 
of whole blood, plasma, or various medications 
is always helpful and may prove of consider- 
able importance at any given moment in sav- 
ing the patient. The ability to establish deftly 
a cut-down type venous cannulation, leading 
to a smooth-worldng infusion, is a modest skill, 
yet one to be admired and cherished by any 
surgeon regardless of his stage of development. 
The employment of intra-arterial transfusions 
under these circumstances, as well as in the ab- 
ruptly exsanguinated person, has created con- 
siderable debate as regards its contribution to 
resuscitation. There is definite clinical and 
some experimental evidence to support the 
idea that it is valuable in many cases and life- 
saving in others. 

The ultimate prognosis in any given case of 
cardiac arrest will depend upon a host of fac- 
tors, but the most important single item prob- 
ably is the duration and degree of the cerebral 
hypoxia. Underlying myocardial disease will 
inevitably prejudice the end result. But, with 
attention to the details listed, dozens of patients 
are now being saved each year who would 
otherwise have been lost because of this abrupt 
and rarely anticipatable disaster. 

Additional Post-anesthetic Care. After 
the patient reaches the recovery ward, or his 
own room, it is best to elevate the foot of the 
bed until he is fully conscious. In addition to 
■the reasons cited previously, the slope promotes 
evacuation of tracheobronchial secretions, dis- 
courages venous stagnation in the lower limbs 
and contributes to a stabilization of the blood 
pressure. To the point that the patient has 
resumed control of his faculties, it is important 
to remove mucous secretions regularly by the 
use of a motor-driven suction delivered through 
a catheter passed through the nose into the 
upper portion of the trachea. Pulmonary ven- 
tilation is promoted by turning the patient at 
intervals, urging him to cough and breathe 
deeply, or through periodic hyperventilation 
with carhon dioxide-oxygen mixtures. These 
measures will contribute to a substantial lower- 
ing of the incidence of atelectasis and post- 
operative pneumonia. 

Transfusions are given until the blood pres- 
sure and pulse rate are stabilized well outside 


121 

any shock range. Sufficient fluids and electro- 
lytes are supplied to anticipate the total daily 
requirements. The patient is kept in the re- 
covery room until fully conscious and free 
from the immediate effects of the operation. 
Some hospitals pro\ade recovery room con- 
xalescent care until the patient is ambulatory 
and has little demand for specialized nursing. 
In uncomplicated cases this is rarely longer 
than seventy-two hours. A mimeographed 
postoperatii^e order sheet senung as a check list 
will simplify the nursing routine and avoid 
overlooking important features in the post- 
operative care. A workable example of this 
arrangement is listed on the following page. 

Nutritional Requirements. Granted that a 
satisfactory preoperatit^e dietary preparation 
has been possible, the total caloric needs of 
the postoperative patient are of small concern, 
if there are no serious complications. As soon 
as peristalsis has been re-established and after 
removal of the gastric tube on the second to 
fourth day, the patient can be permitted a full 
liquid or soft diet. By the fifth to seventh day, 
the convalescent often accepts wnth gusto the 
solid fare which is offered and is soon there- 
after ready for his hospital discharge. Those 
persons of a leaner habitus, after gastric resec- 
tion, may feel the need of several small meals 
daily until the residual pouch and jejunum 
have become somewhat accommodated to the 
new status. Some of these patients tire easily 
from a moderate work load. If they will drink 
1 or 2 ounces of salad oil, topped with fruit 
juice for increased palatability, two or three 
times daily, this preparation will provide energy 
units and but little bulk for those handi- 
capped by their newly limited capacity. 

Wound Healing and Wound Infection. 
The avoidance of wound complications begins 
with the patients preoperative preparation, 
requires adherence to clear-cut technical prin- 
ciples during the operation, and the achieve- 
ment of a smooth convalescence. Failure to meet 
these requirements may result in wound infec- 
tion, hematoma, disruption or evisceration. 

Wound infections usually develop from un- 
recognized, gross, contamination. Strict adher- 
ence to aseptic techniques by the operating 
personnel alone does not suflSice. The greater 
the precautions taken to control air-borne bac- 
teria-laden dust, a cause advanced by air con- 
ditioning that includes filtration, or better an 
electrostatic particle collector, the lower the 
incidence of infected wounds. Canvas hoots 



122 


Chapter 5. Principles of Pre- and Postoperative Caie 

DOCTOR’S POSTOPERATIVE ORDER SI lEET 

1. Vital signs q 15 min. x 4 

q 1/2 lir. until stable then 
q 2 hrs. x 24 brs. 

2. Position: 

Low Trendelenberg 

Semi Fowler’s 

Flat 

3. Hemoglobin stat. and in A. m. 

4. Turn, cough, hyperventilate q 2 hrs. x 24 then 
q 4 hrs. until up. 

5 . Mueller suction prn. . . 

6. Continuous nasal suction. Check prn. at least q 4 hr., and irrigate as necessary with 

solution. 

7. Straight drainage to catheter. Irrigate prn with sterile water. 

8. Urine to cleric’s lab. daily for chlorides until nasal tube is removed. 

9. Chart urine specific gravity h. i. d. 8-6 

10. Weigh daily: litter — Standing—-— 

11. Sedation. 


A/TriT'nlni'nP PT 

q 

h. prn for 

iVivjrpiiiiic ouiiaLv:;' gi* — 

or. 

q 

h. prn for pain 


mg. q 

h. prn for pain 


mg. q 

h. prn for pain 


units q 



Hm. q.. _ 

h 

ATirpnmvrin 

.mg. q 

_ h. 

Other 




13. Fluid order: ADD: 

cc. 5% glucose in distilled water 

— cc. 5% glucose in normal saline 

cc. 10% glucose in distilled water 

— cc. 10% glucose in normal saline 

Transfuse : 

cc. whole blood 

- CC. plasma 

14. Blood loss (Chart on face sheet) 

15. Privileges- 

16. Diet 

17. Chest x-ray stat. 

18. Oxygen therapy: 

Tent — NasaL. 

19. A. M. fluid order: 

placed over the street shoes of every person 
who enters the operating room help in this 
connection. During an operation the wound 
edges can he protected against excessive air- 
borne contamination, as well as against drying, 
by packs moistened with isotonic saline solu- 
tion. Prior to closure, all wound layers should 
have a generous washing with this same solu- 
tion to free them from the rich bacterial 
nutrient present in clot and tissue debris. In- 
cisions so treated will heal more kindly. Care- 
ful hemostasis throughout the operation, gen- 
tle handling of tissues, routine use of fine su- 
ture material, avoidance of mass ligation and 
secondary necrosis, elimination of tissue dead 
spaces and anatomic dissections and repair 
respecting the residual blood supply, all con- 
tribute to a high incidence of primary wound 
healing. Various materials are used in skin 
closures. If metal clips are employed, their re- 


moval in two to four days is wise in order to 
avoid local necrosis and unsightly postopera- 
tive blemishes. Broadly placed, coaphng skin 
stitches may remain five to seven days. The 
smallest cutaneous stitches (5-0 or 6‘-0 silk), 
catching merely the epithelial elements, cause 
no disfigurement when left fourteen to sixteen 
days, and they support the edges during the 
later stages of healing. The routine use of re- 
tention sutures is a matter of individual choice. 
The technique suggested by Price for their 
placement and care seems more logical than 
does that of many older methods. Whenever 
one is required to incise the skin in a person 
with a known tendency towards keloid, pro- 
vision should be made to radiate this area ap 
propriately unless contraindications exist. The 
thoughtful placement of skin incisions in 
natural folds when possible is urged as a means 
of minimizing scar formation. 



123 


Preoperative, Operative 

Certain wounds are unavoidably contam- 
inated during operation, and may become seri- 
ously infected if closed primarily; hence, 
delayed closure is advantageous in these cases. 
The deeper fascial planes are approximated in 
the usual manner. Sutures are placed in the 
siiperhcial structures, but are not tightened. 
A dry gauze pack inserted loosely into the 
incision holds the wound edges apart as the 
entire area is covered wuth a dressing. After 
forty-eight to seventy-two hours the pack is re- 
moved, individual sutures are snugged up, and 
a fresh external dressing is applied. There- 
after, the care is the same as for any wound. 
A tendency to destructive burrowing by a 
pocketed infection is thereby averted, and satis- 
factory healing is assured in the depths as well 
as at the skin edges. 

A wound hematoma usually arises from care- 
less hemostasis. Rarely is it secondary to ex- 
cessive postoperative anticoagulant therapy or 
to an unrecognized preoperative bleeding 
tendency. When one develops, the site should 
be opened and the clot evacuated if the ac- 
cumulation is of any size, lest it become sec- 
ondarily infected. If liquefaction has occurred, 
aspiration under sterile precautions will some- 
times suffice. 

Wound Disruption and Evisceration. 

Wound disruption is the most serious sequela 
of impaired healing in an abdominal wound. 
Many factors predispose to this sometimes dis- 
astrous complication, and in any one instance 
several may contribute. A knowledge of the 
identity of the more common mechanisms in- 
volved and how to avoid and/or overcome these 
hazards will help reduce the incidence of this 
dangerous complication. The more common 
factors contributing to wound disruption and 
e\dsceration are: (1) in the preoperative 
phase: (a) malnutrition, (b) hypoproteinemia, 
(c) chronic anemia, (d) massive recurrent 
hemorrhage with or without shock and (e) 
vitamin C deficiency; (2) in the operative 
period: (a) improper selection of suture ma- 
terial and/or defective suturing technique; (b) 
careless hemostasis, (c) an idiosyncrasy to ab- 
sorbable suture material and (d) a midline or 
long vertical incision; (3) in the postoperative 
stage: (a) violent retching, persistent cough- 
ing, unrelieved hiccoughs, habitual sneezing, 
(h) marked distention and (c) uremia. 

Evisceration may occur after any type of 
incision. Also, it may occur whether the wound 
is closed with sutures which are absorbable or 


and Postoperative Care 

nonabsorbable. Much of the experimental and 
clinical evidence on this score suggests, but does 
not conclusively prove, however, that an 
oblique or transverse incision, closed with some 
form of nonabsorbable material, is less likely 
to be followed by wound disruption. 

Violent straining, or retching, is likely to 
occur as the patient recovers from an anes- 
thetic. During such episodes, if the sutures 
give way, they may produce an audible though 
muffled sound. If wuund disruption thus is 
suspected, most surgeons ad\ise returning the 
patient to the operating room, where he can be 
re-anesthetized, prepared and draped. The 
wound is then opened and the damage, if pres- 
ent, corrected with suture material having 
greater holding power. Postoperati\'e episodes 
of struggling can be readily controlled with a 
small dose of Pentothal given intravenously. 
With the next awakening thus postponed, the 
episodes can be made less violent and painful 
wffien buffered with narcotics. Persistent cough- 
ing may be controlled with ample sedation 
hearing in mind the danger of atelectasis dur- 
ing prolonged suppression of the cough reflex. 
Unremittent, protracted hiccoughing exerts a 
severe strain on an abdominal wound. It may 
develop from a variety of harmless and inex- 
plicable mechanisms, but should suggest the 
possibility of such complications as gastric dila- 
tion, peritonitis with subphrenic abscess, or 
uremia. Active treatment of these conditions 
should be given a high priority and as they im- 
prove, the singultus often abates. In the 
absence of any serious etiologic mechanism, in- 
halation of 5 to 10 per cent carbon dioxide 
in oxygen will frequently interrupt cyclic 
diaphragmatic spasm. Occasionally, it may be 
necessary to block the phrenic nerve on ‘the 
side involved. 

Wound disruption and evisceration may 
occur at any time in the postoperative period, 
hut customarily this regrettable visitation usu- 
ally takes place about the seventh day. The 
patient occasionally volunteers that ''some- 
thing gave away inside.^’ If the skin has re- 
mained intact, the condition is called "wound 
disruption^/ if abdominal viscera are ex- 
truded, it is called "evisceration.” In cases of 
disruption, loops of fiowel can at times be 
palpated through the cutaneous layers. Intes- 
tinal obstruction may occur from knuckling of 
a bowel segment into the dehiscence, and this 
may be the first recognized sign of wound dis- 
ruption if the initial drainage is overlooked. 



124 


Chapter 5. Principles of Pre- and Postoperative Care 


Severe localized pain in an incision, if accom- 
panied by other evidence of mechanical bowel 
obstruction, should suggest this possibility. 
Shock may be present in patients with eviscera- 
tion, and appropriate measures must be taken 
to provide transfusions promptly. Evisceration 
is a major complication, and the patients lile 
is in jeopardy. 

Any sudden staining of the dressings with 
a pink, serous, drainage is virtually diagnostic 
of this complication and makes it mandatory to 
remove all dressings and examine the wound. 
Before taking steps to confirm this, one should 
anticipate the probable need for special dress- 
ings and equipment. The surgeon should don 
sterile rubber gloves, and a cap and mask to 
provide the patient with maximum protection 
from contamination. A sterile covering should 
be at hand to protect any protruding loops of 
bowel from additional soiling. In the event no 
gut is visible or palpable, a few stitches should 
now be removed with an aseptic technique and 
the depths of the wound probed or visualized 
for the site of dissolution. It is unusual not to 
find some area of disruption after an exhibi- 
tion of the characteristic sanguineous drainage. 

Two methods of treatment arc used for dis- 
ruption and evisceration. For a patient who 
is a poor risk, has tenuous parietal fascia, or is 
in profound shock, a conservative technique is 
required which can be carried out at the bed- 
side. Before working on the abdomen with 
either method, the passage of a nasal tube into 
the stomach to evacuate its contents will re- 
duce the likelihood of regurgitation, endo- 
tracheal aspiration, and later pneumonia. 
Topical anesthesia of the nasal pharynx mini- 
mizes retching during tube passage. 

After the adjoining skin and wound edges 
are prepared with an antiseptic, visible loops of 
bowel or other viscera are washed with liberal 
amounts of sterile isotonic saline solution and 
then returned to the peritoneal cavity. They 
are held in place temporarily with a sterile 
towel or a wad of 2-inch gauze packing. If 
co-operation or relaxation is unsatisfactory, the 
patient can be lightly anesthetized with a 
Pentothal and muscle relaxant mixture. Soft 
rubber drains, 1 inch wide, are laid over the 
wound so as to extend beyond its upper and 
lower limits. The skin of the entire abdomen, 
flank and lower part of the chest is then 
cleansed with ether-dampened sponges and 
painted with compound tincture of benzoin. 
Long adhesive strips, which have been flamed 


for bactericidal purposes aud to enhance their 
grip to tiic skin, arc used to draw the wound 
edges together. 1 hese strips, strctehitig diag- 
onally from gluteal lold to axilla, o\erlap each 
other like a spica from below ii|)vvard. The 
defect is clf)sed 1)\' developing traction toward 
the wound edges with each strip. I he inlcrior 
tape end is stuck hrink be! ore it is employed 
to {)Lill into position, lirst, the middle and, then, 
the upper segments, d'lu' rubber drain should 
jut beyond the tape dressing, so as to carry 
awav secretions which might wtaikcn the cf- 
fecti\'cness of the tajic. (hire is rerpiired to 
prewent a bow'cl knuckle (rom being incar- 
cerated in the wound during c'losurca '{'he ap- 
pearance later ()1 signs ol mechanical intestinal 
obstruction and localized pain point to this 
possibility. Ileus is liable to dewdop in most 
cases, d he dressing, il properly functioning as 
a hinder, should remain in place lor at least 
two wmeks. Allliough most ol* these j)atieiits 
will recover, later a ventral hernia at the site 
ol disruption occasionally can be nok'd. 

A healthier patient with wound disruption 
will tolerate a return to the operating room 
where formal repair can he carried out. After 
a nasal gastric tube has been inserted and ar- 
rangements made for whole blootl transfusion, 
the abdominal wall can be resutiired. Steel- 
wire tension sutures, tied clown over a dental 
roll, as pr()]X)sccl by Priee, arc satisfactory. It is 
believed by those who favor this method that 
convalescence is shorter and intestinal obstruc- 
tion is less likely to occur than following other 
procedure and that postoperative hernia is 
largely prevented. 

Drains. The use of drains after cc'rtain ab- 
dominal procedures is a controversial subject 
for there are advantages to be cited on both 
sides of the question. Several types ol* drains 
may be used. The most common ones (Penrose 
tubing, soft-rubber catheters, split drains and 
cigarette drains) rely on capillarity, gravity, or 
slight pressure differences to effect the removal 
of fluid. They customarily seal off from the 
adjacent viscera, when positioned intra-ab- 
dominally, within forty-eight hours. They 
can, however, continue to ooze IluicI, such as 
bile, from a site of leakage for many days. In 
such a case, there should he no haste about 
removing them. The other common type of 
drain is usually a more rigid apparatus. It may 
have the form of a sump pump (I?abcock), a 
double-lumen catheter (Chapin), airwent 
suction (Wangensteen), or a multiple-holed 



125 


Preoperative, Operative 

catheter. These require mechanical suction, 
water or motor-driven, to supplement the other 
forces of drainage and keep the selected area 
dry. They, too, become walled off, but serve 
to keep a site of leakage or a pocket, drier, and 
facilitate healing. The principal purpose of 
drainage is to prevent pocketing internally and 
to provide for external fistulization at the site 
of any maintained leak. Once they have 
ceased to function, intra-abdominal and other 
deep-lying drains should be eased out gradually 
a few centimeters at a time. In this way the 
tract can fill in from the depths. If the drain 
is pulled away completely at one time, the skin 
seals promptly, while pocketing and suppura- 
tion may still develop in the tract. Pain and 
localized tenderness are then noticeable in the 
area for some time, and can even require a 
subsequent re-opening. 

Drains, particularly the firmer types, have 
been accused of abetting or even causing fistula 
formation, when alongside an intestinal anas- 
tomosis. It is felt by those opposed to using 
drains, that in this manner the suture line is 
weakened by proximity to a “rigid foreign 
body.” Those in favor suggest that, if pro- 
vision for such drainage had not been supplied 
when the suture line gave way, subsequent 
leakage and contamination would have dis- 
sected more widely while seeking a path to the 
outside. 

Intestinal Fistula. The treatment of an 
intestinal fistula is usually easier the lower the 
segment of howel from which it arises. When 
the fistula develops from the colon, as after its 
resection or at an appendectomy site, healing 
is slow but steady if no obstruction is present 
in the distal bowel. Constipation should he 
avoided. Some antibiotics and poorly absorbable 
sulfonamides will reduce the bulk and, hence, 
volume of the stool drainage. The higher the 
fistula in the small intestine, the greater the 
difficulties with water and electrolyte loss and 
the more destructive to other tissues are the 
intestinal contents. The juices from a high in- 
testinal fistula will rapidly digest away all 
layers of the abdominal wall This structure 
can he partially protected by the following: 

(1) Proximal control of the volume of in- 
testinal contents by passage of a Miller-Abhott, 
or Grafton Smith, tube down the gut to the 
fistula site with continuous suction on this 
tube and sufficient inflation of the distal balloon 
to obstruct the lumen and thereby reduce the 
amount of discharge. (2) Control at the ex- 


and Postoperative Care 

ternal opening. Motor-driven or water-driven 
suction is delivered through a multiple-holed 
catheter, or pool sucker (McCollum tube), to 
the proximal limb of the fistula, and the ac- 
cumulations are aspirated. (3) Protection of 
the skin and adjacent tissues. Many kinds of 
paste are available. While the dermis is intact, 
powdered aluminum rubbed into the area 
periodically will give considerable protection. 
Ladds paste, brewers’ yeast, and tannic acid 
in lanolin are sometimes effective in controlling 
digestion. (4) Relief of any intestinal obstruc- 
tion distal to the fistula, which would other- 
wise perpetuate the complication. As soon as 
the patients condition permits, the obstruc- 
tion is corrected by lysis of the adhesive bands, 
by a short-circuiting procedure, or by some 
other means of deviation. If the fistula is not 
located too high in the intestinal tract, some 
of the material aspirated from the gut can he 
returned through a secondary gastric catheter 
to the stomach for partial reabsorption in the 
upper portion of the intestine. The amount and 
kind of fluids and electrolytes necessary in 
these cases can tax the judgment of an experi- 
enced clinician. 

Atelectasis, Imperfect expansion of the 
lung, whether massive, patchy or platelike, 
occurring in the postoperative phase, is in- 
variably due to obstruction of a bronchus, or a 
lesser bronchiole, by a mucous plug. Secondary 
factors which may contribute to the develop- 
ment of atelectasis include the following: (1) 
Hypoventilation, which can come from too pro- 
found sedation, hut is commonly secondary to 
pain at the operative site. A vertical upper 
abdominal incision is usually the cause, for as 
the ribs flare out with each breath, lateral ten- 
sion pulls on the wound edges. Morphine or a 
local anesthetic block of the area will often 
increase the depth of voluntary respiration in 
such a subject for the duration of the pain. 

(2) Elevation of the diaphragm. An operation 
which weakens or paralyses the diaphragm is 
commonly followed by some atelectasis. After a 
biliary operation, atelectasis is not uncommon. 

(3) Aspiration of material from the intestinal 
tract. This liquid irritates the tracheobronchial 
mucosa and provokes an inflammatory reac- 
tion, which may progress to pneumonia. In 
milder cases an increase in the volume of local 
secretions, including mucus, occurs and con- 
tributes to the high incidence of atelectasis 
after the accidental aspiration of intestinal con- 
tents. The aspiration of unclotted fresh blood 



126 


Chapter 5. Principles of Pre- and Postoperative C are 


is also provocative of atelectasis and pneu- 
monia. Its removal even by bronchoscopy can 
be troublesome. (4) Overatropiiiization. The 
administration of large closes of atropine inspis- 
sates the mucus and makes it more tenacious, 
thereby increasing the diflicLilty of coughing 
up any sticky plugs. (5) Anesthetic techniciuc. 
Certain gases arc more rapidly absorbed from 
the lungs than is air. Failure to “wash out 
these mixtures at the end of an operation may 
contribute to the appearance later of atelectasis. 
(6) Existing pulmonary suppuration. In the 
presence of bronchiectasis or a lung abscess, 
mucus and other secretions are already formed 
and available. Loss of the cough reflex during 
anesthesia fosters retention and spillage into 
adjacent pulmonary segments. The patient with 
a pulmonary suppuration should spend a period 
just before the operation in the head-down posi- 
tion and try to cough out as much as possible 
of the material accumulated. Bronchoscopy 
should be done after the operation in order 
to evacuate the tracheobronchial -tree again 
and thereby minimize the chances of postopera- 
tive atelectasis. The preoperative use of penicil- 
lin for a few days in any person requiring an 
operation, despite the presence of coexisting 
pulmonary disease, will substantially alter the 
tracheobronchial flora and reduce the volume 
of secretions. The likelihood of postoperative 
atelectasis and l>TOnchopneumonia will be 
reduced. 

Usually, the diagnosis of atelectasis, serious 
enough to cause clinical symptoms, is readily 
made from the chart and the physical findings. 
It can be confirmed by a chest film. The pulse 
is rapid, and the temperature is elevated, often 
out of proportion both to the pulse rate and 
to the apparent illness of the patient. The 
onset of fever is sudden, and commonly a read- 
ing of 102° F. or higher is reached. On 
physical examination, palpation of the trachea 
in the neck may show a deviation to the af- 
fected side. The respiratory excursion is more 
limited over one side than over the other. On 
auscultation a few^ sticky rales can be heard, 
but either the breath sounds are absent or 
bronchial breathing is noted in the area of in- 
volvement. The x-ray picture is essentially that 
of increased density, with a lobar, mottled or 
platelike distribution, in association with eleva- 
tion of the diaphragm, narrowing of the ribs 
and variable degrees of displacement of the 
trachea, mediastinum and heart to the affected 
side. 


I'hc treatment ol aleleilasis begins with aV '• 
tention to the predisposing and contributing 
factors. A lowered ineidcnet' and mi Idea' exam- 
ples of this complication v\'ill result Ironi sudi ' 
prophylaxis. Once the [uoeess has developed, 
it is essential to treat it until it is einvtl. failure 
to reinllate an alelcetalie lung leads to chronic 
pulmonary changes and ii reparable damage. ' 
Recurrent atelectasis in aip' p.erson should alert 
the clinician to the possibdity of intrinsic 
bronchial obstruction Irom an adenoma or car- 
cinoma. Inducing (he paticml to coiigdi, turn- . 
inghim in bed, h\’per\'eniilati()n with 5 to lOper 
cent carbon dioxide in o.xygen and a sharp blow 
over the side of im'olvemc'nt arc oben ellcctive 
means of dislodging a plug and expanding a col- 
lapsed segment. Early ambulation also increases 
the patients pulmonary veiilihttion. Auscul- 
tation of the chest will confirm (he ell’icacy of 
the treatment, or will indicate tht' need lor . 
further active tlierajyv. iinclobronchial aspira- 
tion with a catheter attached to suelion will 
make the patient cough and may inill out the 
offending mucus. If these simple measures fail 
to achieve their purpose, hrcjnchoscopic re- 
moval is indicated, d’bc end results of treatment 
are uniformly good when the disorder is cor- 
rected at an early stage of the process. If 
atelectasis proves intractable or has been 
neglected for many days, re-exptmsion is 
slower, and chronic irreversil)le pulmonary 
changes may occur. 

A tracheostomy often . has lifesaving ad- 
vantages to bring into the management of 
specific problems incident to the control of 
tracheobronchial secretions. Almost its sole 
drawback is the unattractive cervical scar as an 
aftermath. Tracheostomy is at limes a wise 
prophylactic step; at other occtisions it is a well 
chosen supplemental method of retrieving die 
deteriorating situation. With regard to the 
former indication, it may complement the pa- 
tient’s convalescence after extensive surgery 
about the head and neck which has tempo- 
rarily abolished full control of the sw'allowing 
reflexes so that saliva or liquids are thereafter 
prone to trickle into the tracliea. The trache- 
ostomy permits easier and more effective aspira- 
tion of this air-way clogging, mucoid drainage, 
before it can reach the pulmonary terminals. 
After deglutition has been recovered, this ac- 
cessory can be abandoned, For other indivicluals 
with excess secretions, whose prolonged efforts 
to rid themselves of this material have led to ex- 
haustion and a weakened coughing power, the 



Preoperative, Operative and Postoperative Care 127 


addition o£ a tracheostomy is of slight surgical 
magnitude and can avoid loss of the patient s 
life by drowning. There are those patients who 
are comatase, or profoundly debilitated, and in- 
sensate to the healthy cough-provoking mecha- 
nisms of foreign material in the respiratory 
tract. ]\loreo\'er, when a tracheostom\’ is avail- 
able, it simplifies the technique of bronchoscopy 
and, thereby, insures the most complete and 
thorough removal of all retained secretions. 
Too, the ease of handling this situation now, 
and the minimal disturbance to the patient so 
prepared, encourage more frequent recourse 
to endoscopy as needed. 

Alaiiy persons otherwise well versed in post- 
operath^e problems exhibit a surprising re- 
luctance to do a tracheostomy. The potential 
contribution of this simple procedure is 
neglected, or postponed until terminal and ir- 
ret'ersible states of pulmonary congestion and 
pneumonia prevail. The patient is then de- 
stroyed by infection, anoxia, and hypercapnia 
unless last-minute efforts at removing these 
occluding plugs and pools are successful. 

Distention. Distention may develop dur- 
ing the postoperatK^e period in either of 
two forms: acute gastric dilatation, or ileus 
(mechanical or inhibitory). Acute gastric dilata- 
tion may develop after a minor or a major 
operation, including thoracic and cardiac pro- 
cedures. At times the operation may seem al- 
most too inconsequential to cause this complica- 
tion. Acute gastric dilatation may appear also 
in patients with diabetes, during uremia, and 
after fractures. Persons with compression frac- 
tures of the spine treated with a hyperexten- 
sion frame, or a cast, are particularly likely to 
have this complication. The superior mesenteric 
artery-duodenal compression syndrome may 
play a role in patients with spinal fractures 
treated hy means of a hyperextension frame, or 
in patients requiring thoracic operations. After 
a thoracic operation, the patient may have mild 
to moderate gastric dilatation. 

The inexperienced house officer can hardly 
be condemned for thinking first of hemorrhage 
or embolism when called to see a patient, a 
few days after operation, who is obviously in a 
grave condition, showing^ slight cyanosis, 
dyspnea, a rapid, thready pulse and cold ex- 
tremities covered with perspiration. However, 
if percussion of the upper abdomen elicits 
tympanitic notes over a wide area, the pre- 
sumptive diagnosis can be established by pass- 
ing a gastric tube and releasing a gush of air. 


Copious vomiting may never occur as a warn- 
ing sign for this complication, but rather the 
patient repeatedly regurgitates small amounts, 
often hematin-tinged. Enormous quantities, 
se\’cral liters, can accumulate in the stomach, 
and the underlying condition remain unrecog- 
nized. Enough gastric juice may be seques- 
tered in the stomach to lea\^e the patient hypo- 
chloremic. With restitution of adequate quanti- 
ties of salt and water, decompression relief from 
the gaseous distention of the stomach, and oc- 
casionally after a transfusion of plasma or blood, 
the patient usually makes a rapid conva- 
lescence. In a few hours, it may be difficult to 
realize that only a short time ago the patient s 
condition was critical. Failure to recognize and 
treat acute gastric dilatation can, on the other 
hand, lead to a fatal outcome. Prophylaxis is 
as efFecti\'e as therapy and has the added ad- 
vantage of reducing the factor of human error 
through a missed diagnosis. In patients having 
major surgical operations, the routine use of a 
continuous indwelling gastric siphonage system 
wall virtually abolish postoperative dilatation of 
the stomach. When the patient becomes am- 
bulatory and intestinal mobility is restored, the 
danger of this complication becomes minimal, 
and the tube should be removed. 

Meteorism is truly the bane of surgeons, and 
methods helpful in its therapy are worthy of 
emphasis. After any intra-abdominal manipula- 
tion, the intestinal activity is inhibited for 
varying lengths of time up to several days. Any 
extensive degree of traumatic, chemical, or bac- 
terial peritonitis will contribute to the duration 
of this effect. For instance, the use of mass 
ligation which leaves behind clumps of necrotic 
omentum is liable to curtail intestinal activity 
for several days. The local inhibitory effects are 
aggravated further by the increasing intestinal 
distention. The accumulations in the gut con- 
tributing to the distention arc gaseous materia! 
(at least 70 per cent is swalkwed air) and tht‘ 
unabsorbed residue from the oral intake, ])lus 
saliva, gastric and pancreatic juices, bile a! id 
succus entericus. Apparently, the predisposing 
mechanisms for some degree of ileus are present 
in every abdominal procedure. The altcrnaUb'Cs 
are to interrupt the cycle leading to clinical 
ileus or to accept a high incidence ot tliis 
complication and rely on nature and the pa* 
tients durability being able to co|x.' with it. 
The routine use of a nine-holed Wangemteen 
gastric catheter attached to a continuous suc- 
tion equipment properly serviced and 



128 Chapter 5. Principles of Pre- and Postoperative Care 


working order prior to the operation, continuing 
in use throughout the surgery, and maintained 
until intestinal activity is restored two to four 
days afterward, will regularly avert this com- 
plication. Early ambulation hastens the return 
of peristalsis, if severe bacterial or chemical 
peritonitis is not present. Those with experi- 
ence in the management of this problem are 
inclined to agree that it is easier to prevent 
ileus than to overcome it. For the latter situa- 
tion the Miller-Abbott tube or, preferably, the 
Grafton Smith modification, becomes really 
effective only after being passed through the 
duodenum, a maneuver requiring patience and 
skill. In some patients it may be impossible, for 
all practical purposes, to intubate the small 
intestine. 

Another drawback occurs once distention is 
permitted to develop, in that then the differen- 
tiation between inhibitory and mechanical ileus 
must be made. If localized pain, rebound ten- 
derness and leukocytosis are present, a strangu- 
lating obstruction may be the cause. Finally, 
it can be observed that marked abdominal dis- 
tention immobilizes and elevates the diaphragm, 
contributing thereby to a greater incidence of 
atelectasis and other pulmonary complications. 
Some cases of postoperative ileus are well nigh 
intractable, but most will eventually show a 
response to one or more procedures, including 
intestinal siphonage, splanchnic block or spinal 
anesthesia and the use of Pituitrin or Mecholyl. 
Ambulation, when feasible, is one of the best 
means of inducing peristaltic activity. In those 
subjects in whom there is no systemic contra- 
indication to an augmented salt intake, the 
use of 100 to 200 cc. of a 10 per cent sodium 
chloride solution as an enema will often suc- 
cessfully arouse a dormant bowel to assume 
the duties of full-scale peristaltic activity. 

Subphrenic Abscess. Subphrenic abscess 
should be an uncommon complication after 
abdominal operations. It develops most often 
following a perforated appendix or after a rup- 
tured gastric or duodenal ulcer. These are the 
usual causes when there has been no ante- 
cedent surgery. Because of its rarity and often 
insidious onset, exploration of one or both sub- 
diaphragmatic areas is frequently postponed. 
A subphrenic abscess may be anterior, or pos- 
terior, or on the left or right side. Combina- 
tions of these sites are, of course, possible, and 
all four spaces can be infected simultaneously. 
Fever of unexplained origin in a patient 
who has recently been operated upon, or has 


had an antecedent intrajx’ritoncal insult (per- 
forated ulcer or ruptured apjx'ndix), should 
arouse suspicions of a subphrenic abscess. The 
physical (indings may be SLii'iirisingly meager 
or inconsistent and slow to ap[X'ar. To wait 
until all agree upon the diagnosis is often to 
wait too long. X-ray and fluoroscopic study can 
contribute considerable information and sup- 
port to a tentative diagnosis. At fluoroscopy, the 
diaphragm may he found to be clcnaitcd, slug- 
gish or paralyzed. A fluid level pocketed under 
this leaf, and in a specific area outside the 
intestine, is virtually diagnostic. 'The presence 
of a pleural effusion with obscuration of the 
costophrenic sinus is a helpful sign of sub- 
diaphragmatic inflammation. Although many 
times erroneously, this finding is construed to 
have arisen from a pneumonic process. Plain 
and overexposed Bucky films in anteroposterior 
and lateral projections arc useful to confirm 
these findings and to locate the lesion as ac- 
curately as possible. A small quantitv of barium 
in the stomach, with the patient in the head- 
down position, will help demonstrate an ab- 
scess between the diaphragm and the gastric 
pouch. Recognition of a subphrenic abscess is 
most difficult in the early postoperative period. 
Air is invariably present under the diaphragm 
following the operation and may remain easily 
identifiable for two weeks. A tendency toward 
encapsulation and the appearance of a fluid 
level are significant signs pointing more to an 
infection rather than toward some benign 
residuum of the operation. To complicate the 
clinical picture, also, the patient may he febrile 
from causes other than the subphrenic process. 
At times it may be impossible to make the 
categorical diagnosis of subphrenic process. 
Early exploration is often justifiable then on 
the basis that further delay fosters the com- 
plications of a subphrenic abscess (diaphrag- 
matic perforation, empyema, lung abscess and 
bronchial fistula) and hence raises the mor- 
tality rate. 

The principal purpose of operative treatment 
for a subphrenic abscess is to achieve con- 
tinuous (twenty-four hour a day) dependent 
drainage, whether the patient is reclining or 
standing. Except »for an infection in the right 
posterior space, this goal is rarely realized. How- 
ever, when the pocket is so located, the best 
approach is through the bed of the twelfth rib, 
as recommended by Ochsner. For an anterior 
accumulation, some residual puddling is al- 
most inevitable following an anterior drainage 



129 


Preoperative, Operative and Postoperative Care 


procedure whenever the patient is supine. The 
prone position will provide better drainage 
and should be sought and maintained, there- 
fore, as long as tolerated each day. Occasion- 
ally, a secondary posterior opening will be re- 
quired to complete the healing process. The 
preferred approach to an anterior encapsula- 
tion is that of Clairmont through a subcostal, 
extraperitoneal dissection until the area of 
involvement is reached and opened. With 
both the anterior and the posterior approaches, 
the emphasis should be on remaining extra- 
peritoneal until the abscess is evacuated. 
About the area of involvement the o\^erlying 
surfaces become agglutinated, and the free 
peritoneal cavity seals off by the inflammatory 
reaction. Transperitoneal drainage, on the 
other hand, is much more likely to contaminate 
uninvolved visceral and parietal peritoneum, 
with a consequent increase in the morbidity. 
With care, only infrequently will it be neces- 
sary to use this less desirable avenue of ap- 
proach to a subphrenic abscess, 

A unique feature about the subphrenic ab- 
scess problem is the relatively small contribu- 
tion that the antibiotics have made to a reduc- 
tion in its mortality rate. The pace of the dis- 
ease may be slowed and the onset masked to 
some extent, but few of these abscesses seem 
to be cured by antibiotics alone. Hence, one 
should not rely on chemotherapy solely. In 
fact, it is questionable if the recovery is ma- 
terially hastened, after ample drainage, by use 
of bactericidal preparations. These patients 
have a protracted convalescence in general, 
while the body slowly absorbs and heals the 
abscess cavity. 

Parotitis. Acute inflammation of the paro- 
tid gland, except for the association with 
mumps or secondary to sialolithiasis, was for- 
merly more commonly seen than now as a 
postoperative complication. The present liberal 
use of antibiotics, the giving of fluids orally 
after an operation, and the avoidance of dehy- 
dration through better care of the fluid and 
electrolyte requirements, all combine to reduce 
the incidence of parotitis. The most likely 
candidate for its occurrence is the elderly de- 
bilitated patient undergoing a febrile con- 
valescence, poor in oral hygiene and exhibiting 
a parched mucous membrane. The parotid 
lesion is more often initially unilateral, with a 
subsequent occasional appearance on the oppo- 
site side. It is characterized by local tenderness 
and swelling, some trismus and expressible 


pus from a swollen, inflamed Stensen’s duct. 
The pulse rate and temperature become ele- 
vated. Fluctuation is difficult to elicit because 
of the gland’s fibrous septa and tense capsule, 
as well as from the infection’s deep location 
in the gland. As a rule, parotitis will respond 
to antibiotics and to correction of the predis- 
posing mechanisms. Deep x-ray, or radium, 
therapy to the area gives satisfactory results if 
abscess formation has not occurred. Treatment 
carried out early is particularly effective. The 
development of portable deep x-ray therapy 
units which can be brought to the bedside has 
increased the usefulness of this type of treat- 
ment. If abscess formation is suspected, in- 
cision and drainage parallel to the fibers of the 
facial nerve are in order. In a few cases the 
condition is fulminant and progresses rapidly 
unless actively treated. The high mortality 
ascribed to this condition in the past may well 
be related to the appearance of this complica- 
tion as a terminal incident in very poor-risk 
patients. 

Ambulation. Recently, renewed interest 
has de^Hoped in Ries’ recommendation, made 
a half century ago, of early ambulation. At the 
time his idea evoked no widespread interest, 
and it was only tardily submitted to a limited 
practical trial by a few clinicians. Now, many 
subscribe to a program for early ambulation. In 
cases of sepsis, however, conservatism is prob- 
ably still indicated for, in the presence of 
purulent foci or widespread infection, any un- 
due activity is more apt to disseminate the 
process. Rest rather than exercise is indicated 
until the process is under control. The practice 
of early ambulation, in the main, however, has 
been endorsed. Many leaders in obstetrics, 
gynecology, neurosurgery, thoracic surgery, 
orthopedics and general surgery have their 
patients up and about soon after major oper- 
ations. Although there has been a growing 
acceptance of the idea, it has been difficult 
to identify precisely the contributions of early 
ambulation to patient care. Some of the good 
effects are unquestionably obscured by the 
overwhelming benefits of the antibiotics. Su- 
perior anesthetic agents, more liberal transfu- 
sions, better nutritional preparation, a more 
physiologic management of water and electro- 
lyte problems, and other factors have increased 
the difficulty of evaluating the results of early 
ambulation. 

Over and above any ambiguous contribu- 
tions of early ambulation, several effects are 



130 Chapter 5. Principles of Pre- and Postoperative Care 


largely ascribable to it: (1) Pain disappears 
more promptly from the operative site and is 
usually less exquisite. (2) Certain annoying 
postoperative sequelae occur less I'requently 
and in a milder form (ileus, inadequate vesical 
emptying, and hypostatic pulmonary conges- 
tion). (3) The patient’s morale is better, and 
his psychologic reaction Folloiving the operation 
is healthier. This is oF special concern and 
beneht in the care of the elderly patient, For 
once he is up and about, it is easier to arouse 
him from self-pity and discouragement. (4) 
The incidence oF serious complications (hemor- 
rhage, wound disruption and evisceration) is 
not increased. For example, the recurrence rate 
seems no greater if early ambulation is prac- 
ticed after herniorrhaphy. (5) The duration of 
hospitalization after a major operation is short- 
ened, and convalescence at home is hastened. 

The incidence and severity of throvibophle- 
bitis and phlehothrombosis remain approxi- 
mately the same, unfortunately. But then, they 
do after many other prophylactic procedures 
which have been recommended, or else the 
complications of the technique exceed the gains 
in reduced incidence of venous problems. 
Wrapping the patient’s legs, foot to mid-thigh, 
with elastic bandages beginning immediately 
before surgery and redone daily until discharge 
date, is perhaps as beneficial a method as we 
have for routine use. Just why the results in 
preventing venous complications are unim- 
proved after early ambulation is a puzzling 
but recurring conclusion drawn from various 
collected studies. Ambulation is most elfective 
when started within the first twenty-four hours 
after an operation, but this schedule should 
not be inflexible. Those patients who are too 
ill or enfeebled to rise before a major operation 
can hardly be expected to do so shortly after- 
ward. It is wisest to modify the regimen, so 
that as the patient assumes an upright position 
he experiences no serious blood pressure 
changes. A preliminary trial with dangling the 
feet for a few minutes may identify the indi- 
viduals tolerance to assumption of the vertical 
habitus. Any tendency toward syncope is cause 
for temporizing and returning the patient to 
bed; then gradually, after recovery from the 
episode, he may again attempt an erect posture. 
Once he is up, he should be encouraged to 
exercise and then return to bed. If tolerated, 
be should be encouraged to walk more often 
and farther each day. At first, he may be un- 
able to attempt more than a few steps in the 


morning and again in the afternoon. Anibnla- 
tion is a term meaning walking, and this slioyfil 
be therefore the chief activity of that phase ol’ 
the patient’s care. It is an error to inteiprei 
early ambulation as merely getting tlu' patient 
out of bed and into a chair as soon as possible 
after an operation. Keeping him in a ehair ior 
a long time is an abuse ol proper ainbiilalory 
management; it cancels out most of its henehls 
and may cause harm. Venous stasis and throm 
bosis are encouraged b\' this ckpendenew The 
elderly patient who Falls asleep in the' sitting 
position is prone to orthostatic In polcmsion. 
Confusion and disorientation, or such seriou.s 
complications as cerebral thrombosers and car- 
diac arrhythmia, may Follow. l\arl\ ambulation, 
properly supervised, is decidedly bencFieial and 
should be an integral part of anv enmprehen 
sive program for postoperative management. 

Fever. Although (ever in the postoperaliv'c 
patient may arise from a varictv nl' single 
factors, or combinations thereof, certain proba- 
bilities are, however, more frequent Iv causa 
tive and also more likely to exhildt rew'aling 
clues. The patient deserves a careful e\’alimti(m 
of these significant signs and, in the instanet' 
of a sharp rise of the temperature line, it should 
not be construed as ample treatment by the 
house officer merely to order cloubled the dos 
age and variety of antibiotics. In a patient with 
an elevated temperature, the more likely site,s 
arc lungs, urinary tract, opcralix'c area, veins 
of extremities, including the sites of intm 
venous therapy, and abnormal .s\’sttmnc reae- 
tion to drugs. 

A history of burning on urination, lret|uency 
and urgency with voiding and/or rcntil tender- 
ness point strongly to involvement in the uri- 
nary tract. The microscopic examination of a 
centrifuged fresh specimen is then indicated; 
a positive urine culture from a eatheterized, 
or mid-voided, specimen will clinch that con- 
sideration. Also, in any male person cither re- 
peatedly eatheterized or wearing an inlying 
tube, a careful physical examination shoukl 
be done to identify the ]')resence of epididyniitis 
or prostatitis as a focus of suppuration. 

Complete examination of the operative area 
is awkward but this handicap should not serve 
as an excuse to fail to uncover and carefully 
inspect the wound itself. Clean surgical in'- 
cisions should be free of the usual signs of an 
acute inflammatory reaction, and, if not, shoukl 
be suspected of harboring an infection. Elective 
incisions should heal kindly and remain free 



Preoperative, Operative and Postoperative Care 131 


of exquisite tenderness to the sterile gloved, 
careful, palpating finger. If in doubt, the re- 
sponsible person should remo\'e asepticallv a 
few or more sutures and gently part the super- 
ficial tissues so as to reveal any purulent locu- 
lus. If present, \’aluable time will be saved 
in shortening the morbidity and easing the 
patients incisional pain by draining the pock- 
eted abscess; should the area prove clean on 
inspection, the convalescence will not ha\e 
been prolonged. These gaping edges can either 
be snugged together with flamed tape, or re- 
sutured under local anesthesia. Deeper-seated 
purulent accumulations may reveal themseh'es 
in the pehas upon rectal or bimanual examina- 
tion. Abnormal aggregates of air and fluid are 
often recognizable beneath the diaphragm on 
upright films of the abdomen. Too, there may 
be an unusually high diaphragm and pleural 
effusion to be seen on a chest film. 

Displaced loops of bowel about a constant 
area of opacification in association with partial 
small bowel obstruction and clinical ileus are 
strongly suggestive signs of an intra-abdominal 
abscess. Localized and abnormal degrees of 
tenderness over this suspect area will influence 
one’s decision to explore and drain that locus, 
extraperitoneally, if at all feasible. 

Thrombophlebitis is more likely, than those 
instances of traumatic or chemical phlebitis 
secondary to a venoclysis, to produce significant 
elevations of the patient's temperature. This 
complication, or phlebothrombosis, should be 
actively and carefully sought for in any person 
with mild to moderate fever, the exact origin 
of which remains annoyingly obscure since 
prompt precautions and therapeutic procedures 
are in order. 

Abnormal drug reactions, although uncom- 
mon, work their consequences onto the tem- 
perature chart with suflicient frequency to dis- 
rupt even the smoothest running service. 
Whenever the magnitude of the rise in the 
patient’s fever is quite out of proportion to 
the pulse response, and assuredly when the 
more likely other causes have been excluded, 
a medication reaction moves from the realm 
of a possibility to a probability. 

READING REFERENCES 

Amelger, Stuart W.: The Advantages of Tracheotomy 

and the Use of a New Tracheal Tube in the Man- 


agement of Intratracheal Aspiration. Surgery 29: 
260, 1951. 

Cannon, P. R., Wissler, R. W., Woolridge, R. L., and 
Benditt, E. P.: The Relationship of Protein De- 
ficiency to Surgical Infection. Ann. Surg. 120:514, 
1944. ' 

Clark, J. H., Nelson, W., Lyons, C., and Mayerson, 
H. S.: Chronic Shock: The Problem of Reduced 
Blood Volume in the Chronically 111 Patient. Ann. 
Surg. i25:610, 1947. 

Coller, F. A., Campbell, K. V., Vaughan, H. H,, loh, 
V., and Moyer, C, A.: Postoperative Salt Intolerance. 
Ann. Surg.'l 19:533, 1944. 

Elman, R.: Parenteral Alimentation in Surger}'. New 
York, Paul B. Hoeber, Inc., 1947. 

Gamble, J. L.: Chemical Anatomy, Physiology and 
Pathology of Extracellular Fluid. Boston, Spaulding- 
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Hitchcock, C. R., Smith, L., and Varco, R. L.: Surgical 
Applications of an Intra-arterial Transfusion Ap- 
paratus. Surgery’ 32:171, 1952. 

Howard, J. E., Parson, W., Stein, K. E., Eisenherg, H., 
and Reidt, V.: Studies on Fracture Convalescence; 
Nitrogen Metabolism after Fracture and Skeletal 
Operations in Health Males. Bull. Johns Hopkins 
Hosp. 75:156, 1944. 

Kremen, A. J.: The Problem of Parenteral Nitrogen 
Administration in Surgical Patients, Surgerv 23:92, 
1948. 

Lyons, C., and Mayerson, H. S.: The Surgical Signifi- 
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Madden, S. C., and Whipple, G. H.: Plasma Proteins; 
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Miller, F. A., Brown, E. B., Buckley, J. J., Van Bergen, 
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Miller, F. A., Brown, E. B., Wangensteen, 0. H., and 
Varco, R. L.: Certain Effects in Dogs of Inspiring 
15 to 30 per cent Carbon Dioxide. Federation Proc. 
9:89, 1950. 

Schoenheimer, R.: Dynamic State of Body Constitu- 
ents. Cambridge, Mass., Harvard University Press, 
1942. 

Smith, G. A.: A Study of Intestinal Intubation Using 
a Flexible Stylet with Controllable Tip. Surgery 
32:17, 1952. 

Varco, R. L.: Preoperative Dietary Management for. 
Surgical Patients; with Special Reference to Lesions 
of Stomach and Duodenum. Surgery 19:303, 1946. 

Wangensteen, 0. H.: Controlled Administration of 
Fluid to Surgical Patients, Including Description of 
Gravimetric Methods of Determining Status of Hy- 
dration and Blood Loss during Operation. Minne- 
sota Med. 25:783, 1942; Intestinal Obstructions; A 
Physiological and Clinical Consideration with Em- 
phasis on Therapy, Including Description of Opera- 
tive Procedures, 2nd ed. Springfield, III, Charles C 
Thomas, Publisher, 1942; Care of Patient before and 
after Operation, New England J. Med. 236:121, 
1947; The Surgeon and His Trust. Surg., Gynec. & 
Ohst. 84:567, 1947. 



MANAGEMENT OF FLUID AND ELECTROLYTES 
IN SURGICAL PRACTICE 

By BERNARD ZIMMERMANN, M.D. 

Bernard Zimmermann was hor?i in Minnesota and received his education at Harvard 
University and Medical School. He spent time in research in endocrinoloji^y and 
metabolism before beginning his surgical training, which he received at the University 
of Minnesota. He has retained his interest in investigations of the relation hetlvcc^l 
endocrinology and electrolyte and fluid balance in surgical patients. 


Most of the ventures which have resulted 
in present-day surgery would not have been 
successful, nor perhaps even attempted, had 
it not been for the concomitant development 
of an extensive body of information pertaining 
to the support of the physiologic needs of pa- 
tients following extensive surgery. Radical 
visceral cancer surgery, modern thoracic sur- 
gery and cardiovascular surgery exemplify the 
priority of such fundamental knowledge. Many 
of the early steps in this field were taken by 
pediatricians, such as Gamble, who investigated 
fluid and electrolyte losses from the body in 
abnormal states and the chemical alterations 
which losses produce on the composition of 
the body fluids. These alterations mainly con- 
cerned sodium, chloride and bicarbonate and 
it took another pediatrician to indicate the 
importance of derangements of intracellular 
composition. Thus, surgeons, following the 
work of Darrow on potassium losses in infantile 
diarrhea, soon appreciated the significance of 
this ion in the correction of postoperative elec- 
trolyte deficits. Another aspect of the develop- 
ment of basic knowledge which is now appli- 
cable to the patient following major surgery 
is the newer understanding of those metabolic 
effects which accompany all major traumatic 
incidents to which the human body may be 
subjected. From the work of Cuthbertson and 
Albright and the observations made on animals 
by Selye and his colleagues, the concept has 
been established that the patient who has un- 
dergone major surgery, regardless of the type 
of operation, is vastly different from the nor- 
mal individual His need for some substances 
is far greater, his tolerance for others is less 
and the problem has become much more com- 
plicated than the simple calculation of require- 
ments from the difference between what goes 
into the body and what comes out. 

Page 


Physiologic Characteristics of the Postop- 
erative Patient Trauma of a degree compar- 
able to that represented by major surgical 
operations results not only in rather character- 
istic alterations in metabolism hut also in gross 
changes in such tissues as the formed elements 
of the blood and the lymphatic system, the 
thymus and the adrenal glands. Nitrogen and 
carbohydrate balance arc altered so that blood 
sugar tends to be elevated, gluco.se tolerance 
is decreased, glycosuria is not uncommon and, 
in instances in which marginal glucose toler- 
ance exists, transient or even permanent dia- 
betes may be precipitated by a major surgical 
pmcedure. Along with this, the balance of 
nitrogen becomes negative as measured by an 
increased output of nitrogen in the urine and 
a relative inability of the organism to utilize 
exogenous amino acids for the synthesis of 
structural body proteins. Sodium and chloride 
tend to be withheld from the urine and, in the 
immediate postoperative phase, urinary concen- 
trations of these two ions may drop to almost 
zero even when the amounts given arc greater 
than that normally necessary for daily replace- 
ment. Urinary potassium concentrations, on 
the other hand, are regularly elevated. Potas- 
sium balance becomes negative and that this 
potassium diuresis is not entirely the result of 
tissue breakdown can be proved by demon' 
strating that the potassium-to-nitrogen ratio of 
the urine is greater than that which character- 
izes the interior of the cell 
The postoperative patient is frequently 
oliguric, even in the absence of preceding shock 
or other factors which might be expected to 
predispose to disturbances of renal function. 
More consistently than this, however, postop- 
erative patients have an intolerance to water. 
This implies that their diuretic response to a 
water load is impaired so that they excrete 

132 



Management of Fluid and Electrolytes in Surgical Practice 


excess water sluggishly and may suffer the 
consequences of dilution or hydremia before 
the hidneys are able to respond to an excess of 
administered fluid. 

The metabolic alterations are associated in 
patients following surgery, and in experimental 
animals following trauma, with certain morpho- 
logic changes including depression of the num- 
ber of lymphocytes and the eosinophils in the 
blood, involution of the lymphoid tissues such 
as the thymus and enlargement of the adrenal 
gland. The underlying factor in these morpho- 
logic changes and certain of the metabolic 
effects is the production of an increased amount 
of hormones by the adrenal cortex. It must be 
recognized, however, that no single mechanism 
is likely to be responsible for all of the meta- 
bolic phenomena which characterize the re- 
sponse to surgery. It is likely that these reac- 
tions have a definite protective effect on the 
economy of the organism although the nature 
of this protection remains largely obscure. 
Most investigations of this subject have cen- 
tered around the activation of the pituitary- 
adrenal system in response to stress. It is very 
clear that the pituitary rapidly secretes an in- 
creased amount of adrenocorticotrophic hor- 
mone to which the adrenal responds with the 
output of one or more steroid hormones with 
potent metabolic activity. The work of Hume 
and others has further indicated that the an- 
terior pituitary is stimulated by the activation 
of certain centers in the hypothalamus, the re- 
lationship of which to the hypophysis appears 
to be a humoral rather than a neural one. It 
is likely that more than one mechanism is re- 
sponsible for the discharge from these hypo- 
thalamic centers. 

At least three types of hormone are known 
to be produced by the adrenal cortex. As 
defined by their function rather than their 
chemistry, these include the glucocorticoids 
which are responsible for regulation of carbo- 
hydrate protein metabolism; the androgens 
which in addition to masculinizing function 
cause positive nitrogen balance, and mineralo- 
corticoids which are predominantly concerned 
with the regulation of sodium and potassium 
balance. That substances capable of profoundly 
altering organic metabolism are mobilized by 
the adrenal gland following surgery has been 
demonstrated by the finding of increased hor- 
mones of this type in the postoperative urine, 
as well as the presence of ll-oxy-17 hydrocorti- 
coids in the blood. The consistent occurrence 


133 

of eosinopenia following surgery also suggests 
the presence of this same type of hormone, al- 
though less significance can now be attached 
to the fall in eosinophil count than w^as be- 
lieved to have been justified by the early 
experiments relating eosinophil depression to 
adrenal cortical activity. The endocrine basis 
for postoperath'e alterations in sodium and 
potassium regulation was not known until the 
relatively recent discovery of ^qldosterone and 
the demonstration of the presence of this sub- 
stance in various pathologic states associated 
with sodium retention. Recent experiments 
have demonstrated, furthermore, that this sub- 
stance is actually mobilized in large amounts 
by the adrenal following surgery. The mecha- 
nism wTich stimulates the adrenal gland to 
produce a substance with high sodium-retain- 
ing and potassium-excreting potency, however, 
is still obscure for there is a great deal of evi- 
dence that this particular function of the 
adrenal gland is not under the control of the 
anterior hypophysis. It is likely, moreover, 
that none of these reactions are exclusively 
regulated by the endocrine system, and it must 
be remembered in this connection that hor- 
mones in general only catalyze and do not orig- 
inate metabolic processes for which the funda- 
mental enzymatic mechanism lies in the cell. 
There is a considerable body of evidence sug- 
gesting that in both man and animals, without 
adrenal glands ^ but maintained on constant 
amounts of adrenal replacement, nitrogen ex- 
cretion, sodium retention and potassium los^ 
can all be induced by the imposition of non- 
specific stress. This strengthens the notion that 
the underlying pathways for these reactions 
exist in the basic enzymatic machinery and do 
not depend exclusively on an acceleration in en- 
docrine function. Nevertheless, the importance 
of the endocrines for preservation of life under 
circumstances of systemic stress is adequately 
demonstrated by the almost uniformly fatal 
results of minor operations inadvertently car- 
ried out on patients with adrenal insufficiency. 

A seeming paradox exists in the fact that 
during the period following extensii^e surgery, 
when sodium and chloride are rigorously with- 
held from the urine, plasma levels of these ions 
are commonly reduced. Mere dilution associ- 
ated with a tendency to water retention has not 
been adequate to explain this phenomenon. A 
generalized movement of sodium into the cell 
accompanying the loss of potassium would 
appear to be a significant factor underlying this 



134 


Chapter 5 . Principles of Pre- and Postoperative Care 


discrepancy. Ne\'ertheless, the over-all pattern 
t)l' shifts and re-distribution of both water and 
solutes following surgical stress have been lar 
from completely described, and a search for 
specific reservoirs which may be responsible lor 
the diversion of sodium ion in particular is 
beintt continued bv many investigators in this 
heldl' 

Fluid Compartments; Tlieir Boundaries and 
Constituents. The tendency of clinicians to 
describe abnormalities of fluid and electrolyte 
physiology in terms of plasma values results 
only from the relative simplicity with which a 
sample can be drawn from the circulating blood. 
Although blood values are obviously of great 
importance, any rational consideration of ab- 
normalities of fluid and electrolyte physiology 
must take into account all the major fluid 
spaces and the nature of the boundaries which 
separate them. 

The extracellular fluid is composed of the 
blood plasma and the interstitial fluid. Values 
for this volume vary from 17 to 20 per cent 
of the body weight depending upon the method 
used for determination. More recent methods 
give lower values. Older determinations indi- 
cated that the total body water was about 70 
per cent of the body weight. Measurements 
using deuterium oxide -suggest average values 
of around 61 per cent for men and 52 per cent 
for women. 

The blood plasma and interstitial fluid are 
essentially the same in composition except for 
the difference in protein concentration which 
results from the relative impermeability of the 
capillary to these large molecules. The com- 
position of the cell fluid, on the other hand, 
differs radically from that of the extracellular 
fluid. Whereas the sodium is the major extra- 
cellular cation 7 potassium dfccupies this position 
in the cell where phosphate is the predominant 
anion. Despite this, it is not true as was once 
believed that sodium is completely excluded 
from the cell. A definite amount of sodium ion 
constitutes a portion of the intracellular ionic 
structure and there is a great deal of evidence 
that this quantity may be increased under cir- 
cumstances of injury and disease. It must also 
be recognized that the relative exclusion of 
sodium from the cell is not a matter of per- 
meability of the cell wall. Individual sodium 
ions have been shown by tracer techniques 
readily to permeate the cell membrane showing 
that maintenance of an unequal gradient is 
not a matter of permeability, but an active 


process requiring the cxpcndil li rc of mciaholic 
energy. The perpetuation of these une<{ual 
concentrations is, thcrclorc, a function of 
normal ceils and a characteristic of hie as sig 
nificant as the utilization of ox\gen and the 
production of carboji dioxide, it is typical, 
moreover, of "sick cells" that tlu'sc gradients 
tend to break down and the intracellular con- 
centrations approach those of the surrounding 
medium. 

The values mentioned ab()\'c for the volimies 
of the intracellular and exlraeellular compart- 
ments describe the situation in the normal in- 
dividual. It is f)f some importance to consider 
the factors which regulate these ^olumc rda- 
tionships. The critical quantity in this regard 
is the extracellular sodium, lor the intracel- 
lular volume does not depend on the a\'aila})Ie 
w^atcr of the extracellular space hut rather its 
total ionic concentration. Since sodium exists 
in largest concentration, the level of this ion 
is the most important controlling factor. /\ de- 
crease in sodium ion concentration results iji a 
movement of water into the cells with conse- 
quent enlargement of the intracellular volume 
and similarly an increase in sodium concentra- 
tion results in cellular dehydration. Such 
changes in tonicity underlie many of the 
clinical manifestations for which de\aations of 
water and electrolyte balance are res[)onsil)lc. 

Requirements of Siirgicjii Patients. I he 
initial consideration for fluid ref)lacciuent is 
the basal requirement for tlic human being 
who, for reasons of disease or surgery, is denied 
the oral route of alimentation. The mininiiil 
quota for an adult must take account of an 
insensible loss through the skin and lungs rang- 
ing Irom 600 to 1000 cc. and an anticipated 
urine output of 1000 to 1500 cc. Insensible 
losses may, of course, be far greater than this, 
particularly in the circumstances of fcv'cr or 
prolonged surgery under heavy cloth draping. 
Accurate studies on patients with anuria, in 
whom the control of water administration must 
be extremely precise, have indicated that in- 
sensible losses may on occasion be consider- 
ably lower than the above-mentioned limits, and 
as little as 400 to 500 cc. of exogenous water 
may sometimes be required. The factor of in- 
sensible loss is, therefore, not only variable but 
highly unpredictable and the ignorance of 
this quantity is the basic reason for the unique 
value of the body weight in assessing states of 
hydration. In addition, therefore, for accurate 
measurement of the fluid intake and output. 



Management of Fluid and Electrolytes in Surgical Practice 135 


TABLE 1. VALUES FOR CONTENT OF SODIUM, POTASSIUM AND CHLORIDE IN 
GASTROINTESTINAL TRACE LOSSES (Milliequivalents per Liter) 




Na 

K 

Cl 

Gastric 

Average 

59.0 

9.3 

89,0 

(Fasting) 

Range 

6.0-157 

0.5-65.0 

13.2-167.2 

130 specimens 

^ 2/3 Cases 

31.0-90.0 

4.3-12.0 

52-124 

Small bowel 

Average 

104.9 

5.1 

98.9 

(Miller-Abbot suction) 

Range 

20.1-157.0 

1.0-11.0 

43.0-156 1 

89 specimens 

2/3 Gases 

72-128 

3. 5-6.8 

69-127 

Ileum 

Average 

116.7 

5.0 

105 8 

(Miller-Abbot suction) 

Range 

82-147 

2. 3-8.0 

60.7-137.0 

17 specimens 

7 patients 

2/3 Gases 

91-140 

3. 0-7. 5 

' 82-125 

Ileostomy 

Average 

129.5 

16.2 

109.7 

(Recent) 

Range 

92-146 

3.8-98.0 

66-136 

25 specimens 

7 patients 

2/3 Gases 

112-142 

4.5-14.0 

93-122 

Cecostomy 

Average 

79.6 

20.6 

48.2 

20 specimens 

Range 

45-135 

3.7-47.3 

18-88.5 

9 patients 

2/3 Gases 

48-116 

11.1-28.3 

35-70 


* From Randall, H. T.: Water and Electrolyte Balance in Surgery. S. Clin. North America 32AS1, 1952. 


surgical patients should be weighed daily on a 
balance which is accurate to 0.1 kg. and the 
weight recorded on the chart along with the 
fluid balance data. In patients too ill to stand 
on a scale, this can be accomplished by a bal- 
ance which utilizes a litter upon which the 
patient is lifted from his bed. 

Large amounts of sodium chloride are not 
required for maintenance of patients who do 
not suffer from external losses. The normal 
kidney can restrict sodium excretion to much 
less than that contained in 1 gm. of sodium 
chloride (17 mEq.) and the insensible water 
loss excluding palpable sweat contains only 
traces of sodium salt. This ability of the kidney 
to conserve in the absence of intake does not 
hold for potassium ion, since 30 to 40 mEq. of 
potassium may be excreted by patients receiv- 
ing none by mouth or parenteral route. It is 
necessary, therefore, to include in a parenteral 
regimen at least 2 to 3 gm. of a salt such as 
potassium chloride for routine maintenance. 
This, however, should not be given immediate- 
ly after surgery nor until normal renal function 
has been adequately established. The losses of 
potassium may, of course, be much greater fol- 
lowing the stress of major surgery, burns and 
trauma. In addition to the basal amounts of 
fluid to provide for urine output in the place 
of insensible losses, parenteral administration 
must include volume-for-volume replacement 


of water lost through the- abnormal routes of 
tubes and fistulae. The replacement of solutes 
lost through these channels must take into 
account the origin of the secretions, for the 
ratio of sodium to chloride in various gastro- 
intestinal fluids varies greatly from that -of 
plasma. Their loss will produce not only over- 
all electrolyte depletion but also profound dis- 
turbances in acid-base equilibrium. Thus, with- 
drawal of normal gastric juice which contains 
more chloride than plasma and very little so- 
dium rapidly produces alkalosis. Conversely, 
pancreatic juice which possesses a sodium con- 
centration comparable to that of plasma but 
relatively little chloride causes acidosis when 
lost from the body in significant amounts. Bile 
is, more alkaline than plasma though its so- 
dium-to-chloride ratio is not nearly so high as 
that of pancreatic juice. Intestinal fistulae, ex- 
cept for high ones, tend also to produce acidosis 
because of relatively greater sodium losses. 
Most aspirates from tubes and fistulae are of 
mixed, and frequently of undetermined, origin 
and it may be occasionally necessary to do 
actual measurements of solutes in the secretions 
in order effectively to provide for their replace- 
ment. 

For common situations, average values for 
gastrointestinal fluids based on previous ex- 
perience are adequate and Table 1 and Table 2 
from the work of Lockwood and Randall pre- 



136 Chapter 5. Principles of Pre- and Postoperative Care 


TABLE 2. SODIUM, POTASSIUM AND CHLORIDE CONCENTRATIONS OF BILE AND 
PANCREATIC JUICE (Milliequivalcnti per Liter)* 



Na 

K 

CA 

Bile 

Average. 

145.3 

5.2 

99.9 

22 specimens 

Range .... 

122-164 

3. 2-9. 7 

77-127 

12 patients 

2 /3 base> 

134-150 

3. 9-6. 3 

83-110 

Pancreas , 

Average . . 

141.1 

4.6 

76.0 

3 patients j 

Range 

113-153 

2. 6-7. 4 

54. 1-95.2 


From Randall, H. T.: Water and Electrolyte Balance in Surgery. S. Clin. North America J2;458, 1952. 


sent some mean concentrations oF sodium, po- 
tassium and chloride for typical secretions. 
Reference to these tables is useful in approxi- 
mating the requirements in average cases. To 
leplace the acid secretion from a normal 
stomach, it is usually only necessary to use 
sodium chloride solutions even though this 
may entail giving an excess of sodium ion. 
Since a normal kidney excretes the sodium, acid 
salts such as ammonium chloride are rarely 
necessary. However, in the management of 
pancreatic, biliary and intestinal fistulae where 
sodium loss predominates, correction can not 
be achieved by the use of sodium chloride 
alone and alkaline replacement solutions such 
as sodium bicarbonate or lactate are necessary. 
In this connection, it will be recalled that the 
plasma is normally alkaline. The administra- 
tion of sodium chloride alone is, therefore, an 
acidosis-producing procedure although the kid- 
ney can normally compensate for this effect. 

Disturbances of Acid-Base Equilibrium. 
Clinical disturbances of acid-base balance may 
be of either metabolic or respiratory type. 
Whereas, in the past, metabolic disturbances 
were considered to be vastly more frequent, the 
recent growth of thoracic surgery and the more 
intensive study of inhalation anesthesia have 
served to emphasize the comparative frequency 
with which respiratory disturbances of acid- 
base regulation actually occur in surgical pa- 
tients. Consequently, it is of great importance 
that in evaluating cases of acidosis or alkalosis 
the necessary data be available to demonstrate 
clearly what the underlying basis for the clini- 
cal disturbance in pH is. In most institutions, 
a measurement approximating the plasma bi- 
carbonate such as the carbon dioxide combining 
power is used for clinical purposes. Reliance 
on this value alone is frequently adequate if it 
is kept in mind that this quantity is by itself no 
index of the direction of the pH change. It will 
be recalled in this connection that the pH main- 
tained by the buffering system of the plasma is 


related to the bicarbonate of the blood and 
the dissolved carbon dioxide, or carbonic acid, 
by the familiar Henderson-Ilassclbalch equa- 
tion: 

, , BHCO3 
VB. = pK 4- log 

The bicarbonate of the plasma can be altered 
by changes in its rate of renal excretion and 
the carbonic acid concentration depends on the 
rate at which carbon dioxide is removed by the 
lungs. By their individual control of these two 
quantities, the lungs and kidneys are the organs 
primarily responsible for the preservation of 
normal pH in the face of circumstances tending 
to disturb it. In deviations ol a ; primaiw 
metabolic nature, the initial effect is on the bi- 
carbonate whicfi is decreased in acidosis and 
increased in alkalosis. The respiratory apparatus 
responds to shift the carbonic acid in the same 
, BHCOa 

direction so that the ratio which is 

normally 20:1 is minimally altered. Respira- 
tion is, therefore, accelerated in acidosis and 
depressed in alkalosis. In disturbances of a 
primary respiratory nature, however, the initial 
effect involves the carbonic acid. Compensa- 
tions must be made by the kidneys which re- 
tain or excrete bicarbonate. They retain bicar- 
bonate when carbonic acid has been inade- 
quately removed by the lungs and they excrete 
an excess of bicarbonate to compensate for the 
alkalosis which follows hyperventilation.. Therc- 
pre, since the final bicarbonate value, which 
is the most commonly used index for acid-base 
disturbances, is elevated in metabolic alkalosis 
and respiratory acidosis, and depressed in 
respiratory alkalosis and metabolic acidosis, it 
is obviously not possible to distinguish between 
acidosis and alkalosis on the basis of the carbon 
dioxide cqmbining power alone. In most in- 
stances, the clinical information obviously 
points to a disturbance which is primarily of 
metabolic, or of respiratory, origin. Occasion- 



Management of Fluid and Electrolytes in Surgical Practice 137 


Effect on Plasma 



Figure 1. Hypochloremic alkalosis. EEect of sev- 
eral days of nasal tube suction, without adequate chlor- 
ide replacement, on the composition of the plasma. 
Note reduction of chloride with expansion of bicarbo- 
nate and essentially normal sodium. 

ally, however, the situation is not clinically 
obvious and the complete acid-base picture 
must be obtained by establishing a value of a 
second of the three possible variables in the 
Henderson-Hasselbalch equation. This is done 
ordinarily by the determination of the blood pn. 

Metabolic alkalosis is most commonly seen 
in surgical patients as a result of loss of large 
amounts of gastric secretion, a material which 
has high chloride content with relatively low 
concentrations of sodium. It is ordinarily lost 
either through vomiting or continuous inlying 
gastric suction. Alkalosis can develop in as 
brief a time as twenty-four hours in the face of 
total diversion of gastric content. Figure 1 illus- 
trates the ionic pattern in such a case com- 
pared with the normal concentration. As was 
mentioned above, this simple situation can be 
corrected by administration of chloride ion in 
the form of sodium chloride, and acid salts are 
rarely indicated. 

A more complicated situation leading to 
metabolic alkalosis is that associated with potas- 
sium deficiency. It is most frequently recog- 
nized under circumstances in which repeated 
administration of sodium chloride or even am- 
monium chloride Results in no alleviation of 
metabolic alkalosis. Though it was originally 


Deficiency 

mEq/L 


ISO- 



o'" “ 

125- 



HC0| 

100- 




75- 


Na + 

Cl ‘ 

50- 




26- 










ORG. ACID 


Kf 


PROTEIN* 


ca + + 



Mg + + 



Figure 2. Hypochloreinic alkalosis resulting from 
potassium deficiency in a patient following prolonged 
parenteral therapy without potassium replacement. 

described by Darrow as a complication of 
infantile diarrhea, it is now seen at least as 
frequently in association with high intestinal 
obstruction and, particularly, in patients who 
have had prolonged parenteral maintenance 
without adequate amounts of potassium ion 
(Fig. 2). The increased extracellular bicar- 
bonate under these circumstances is related to 
the high intracellular sodium which results 
from the movement of the latter ion into the 
cell as a mechanism for replacing the lost intra- 
cellular cation. A persistent hypochloremic al- 
kalosis which is typic^ of the situation can be 
reversed only by 'the administration of potas- 
sium ion. The diagnosis is usually made merely 
by the presence of so-called 'refractory alka- 
losis.'^ Serum levels of potassium are usually 
low, although they need not always be. The 
characteristic electrocardiographic findings- 
prolongation of the Q-T interval, depression of 
the RS-T segment and eventually inverted T 
waves~are valuable confirmatory signs. , 





138 


Chapter 5. Principles of 


Pancreatic Fistula 

mEq/L 



Figure 3. Hyponatremia acidosis. The result of 
chronic sodium loss through a pancreatic fistula. Note 
reduction of sodium with corresponding contraction of 
bicarbonate. Cross-hatch indicates normal values as- 
sumed Ccations) or determined by subtraction (anions). 

The nature of the physiologic state which 
follows surgery and the stress associated with 
serious surgical diseases explain the frequency 
of potassium deficiency as a surgical complica- 
tion. Reference to Table 1 will indicate the 
amounts of potassium in milliequivalents per 
liter of drainage that may be lost from the 
body through gastrointestinal siphonage. Even 
when gastrointestinal siphonage is employed, 
however, the loss through the gastrointestinal 
tract is usually not the largest source of nega- 
tive potassium balance, for even under normal 
circumstances an individual receiving no potas- 
sium by mouth may put out large amounts of 
urine and under circumstances of stress, im- 
posed by a major surgical procedure or acute 
intestinal obstruction, these urinary losses may 
he greatly increased. 

Acidosis of metabolic origin is frequently 
seen following the loss from the body of secre- 
tions possessing high sodium concentration. 


Pre- and Postoperative Care 

The typical case is that of pancrc<iLic I'lstula. 
Pancreatic juice which possesses a sodium con- 
centration comparable to that ol plasma but 
very little chloride is almost an isotonic s(du- 
tion of sodium bicarbonate. Diversion of this 
solution from a normal path of being secreted 
and reabsorbed from the intestine results verv 
rapidly in profound acidosis with a blood pic- 
ture of low sodium and low bicarbonate \'alues. 
The electrolyte picture resulting from a ehronie 
pancreatic fistula is illustrated in bigure 3. A 
similar situation is, of course', j^rodueed by so 
dium loss through fistulae from the lower in- 
testine where the sodium-to-chbaade ratio is 
also high. Reversal of the blood electrolyte pic- 
ture in these situations cannot be ordinarily ac- 
complished with sodium chloride, and the use 
of sodium solutions with labile or metaboli/abh' 
anions, such as sodium lactate or sodium bi- 
carbonate, is ordinarily required. 

The examples of acidosis just dcscj'ibcd re- 
sult from the Joss of the extracellular cation 
or what w^as rcl erred to in the older clinical 
terminology as “fixed base.” Another type is 
the result not of loss of base but of accuiruila' 
tion of abnormal acids which results in dis 
placement of bicarbonate. An example of this 
is the acidosis which accompanies uremia with 
accumulation of phosphate, sulfate and organie 
acids. Another is the picture which results from 
the excessive rcabsorption of chloride from the 
intestine following surgical procedures in 
which the ureters are transplanted into tlie in- 
testinal tract. This so-callcci chloride acidosis 
frequently follows such ]:)roccdurcs but is more 
likely to exist when drainage of the intestinal 
segment is inadequate or when poor renal 
function exists in addition to discharge of 
urine into the intestine. 

Respiratory acidosis associated with anes- 
thesia and thoracic surgery has become a matter 
of increasing significance in recent years. It is 
important to recognize that the administration 
of oxygen to individuals with respiratory im- 
pairment resulting from pulmonary disease, or 
inadequate pulmonary tissue, or impairment of 
motor respiratory activity, will maintain oxygen 
saturation of the blood hut may not achieve 
adequate removal of carbon dioxide. The pro- 
found consequences of respiratory acidosis in 
the genesis of cardiac arrhythmia and cardiac 
arrest have been discussed. 

Disturbances of Fluid Volume* A consid- 
eration of daily importance in the management 
of postoperative patients is the maintenance of 



Management of Fluid and Electrolytes in Surgical Practice 139 


normal extracellular fluid \^olumc. This quan- 
tity, which is \'eiy sensitively regulated in the 
normal individual is readily subject to distor- 
tion when the oral intake, or the effect of 
thirst, is removed and when renal regulations 
of fluid volume ma}' be impaired. Dehydration 
in the strict sense refers to the effects on the 
body of w^ater loss alone. It mos^t frequently is 
used, however, to describe the deficiency of 
water in combination with electrolytes. Pure 
water dehydration is actually rare. The fa- 
miliar signs of dehydration are loss of turgor 
of the skin, sunken eyes, and dryness of the 
mucous membranes. Change in body weight is 
the best index of the development of dehydra- 
tion. Serum electrolyte concentrations can be 
elevated, depressed, or normal and therefore 
give no indication of the over-all deficit of ionic 
components. If a patient admitted to the hos- 
pital has been vomiting, or has suffered other 
palpable fluid losses, it must be remembered 
that if he has not been drinking, water loss al- 
most invariably exceeds electrolyte loss so that 
it is best to begin hydration with solutions 
which are dilute with respect to ionic con- 
stituents. Subsequent blood chemical deter- 
minations frequently reveal the presence of 
electrolyte deficit as a more normal state of 
hydration is approached. 

Edema in association with surgery was fre- 
quently seen in earlier days when "physiological 
saline” was used routinely as a hydrating solu- 
tion. After the recognition by Coller and his 
associates of the tendency for patients to retain 
sodium in the period after surgery, excessive 
use of sodium chloride was almost universally 
discontinued. Postoperative edema became far 
less common. In this situation, as with dehydra- 
tion, the serum levels of ions do not, of course, 
give any index of the over-all excess of extra- 
cellular electrolytes which may be present. The 
I'lmiliar clinical signs of pulmonary and periph- 
eral edema are obviously of the greatest im- 
portance and serial body weight determinations 
will demonstrate incipient fluid retention long 
before clinical edema is apparent. 

Disturbances of Concentration. Reference 
has already been made to the importance of 
the sodium concentration of the extracellular 
fluid and its critical role in the over-all distribu- 
tion of water henveen the cells and the fluid 
which surrounds' them. Bcau/se of the im- 
portance of this conc'entnitioie it is not sur- 
prising that the iiofinn! sodium level is main 
tained within rather nmnni liiuiis, Newatite 


Postoperative 
’’Water Intoxication" 


mEq/L Norma! " Total Base " 

, j 



Figure 4. Water intoxication occurring thirty hours 
after operation (colectomy) in an elderly woman with 
cardiac disease who had been maintained on a low 
sodium regimen prior to surgery. 

less, following surgery and in the absence of 
oral intake, elimination of the factor of thirst, 
and with certain impairments in renal func- 
tion, disturbances in the normal regulation of 
sodium do occur. As lias already been pointed 
out, such a deviation represents in effect an ab- 
normality in the over-all effective osmotic prop- 
erties of extracellular fluid. 

It was stated above that, following major 
operations, the sodium concentration of the 
plasma tends to drop despite the lact that so- 
dium balance inclines to be positive. This situa- 
tion results from an intolerance of the post- 
operative patient to affnimrsfereclAvater with 
subsequent dilution and also from factors hav- 
ing to do with translocation of the sodium ion 
possibly into other reservoirs which are at pres- 
ent poorly understood. Although this frecjuent 
deprcs.sion of sodium eonotaitration is not 
ordinarily acvomf>anii“d 1)\ sv'inptoms, if occa- 
sionally is severe enough to cause preffound 
hinetionaf disturb.uices. Most c lufstaficling of 



140 Chapter 5. Principles of Pre- and Postoperative Care 


thebe involve the central nervous system which 
reflects the depression of sodium concentration 
and reacts to intracellular shift of water by the 
physical signs of stupor, irrationality, neuro- 
muscular phenomena and sometimes convul- 
sions. Depending on the circumstances leading 
to such clinical symptoms, they are referred to 
as “water intoxication,” “low sodium syndrome" 
or “paradoxical hyponatremia.” The most pro- 
found effects are produced when an injudicious 
amount of water is given to a patient within 
the first tw^o to three days after surgery. Never- 
theless, cases of so-called water intoxication 
have been ohserc^ed under circumstances in 
which entirely appropriate amounts of water 
have been administered (Fig. 4). This phe- 
nomenon has been particularly observed follow- 
ing the operation of valvuloplasty for mitral 
stenosis. The cardiac impairment in these in- 
dividuals prior to surgery creates an even 
greater intolerance to administered water than 
the usual surgical patient exhibits. It is of 
great interest that the total measurable sodium 
in these individuals actually tends to be high 
as does their total extracellular space. This fur- 
ther emphasizes the fact that it is the concen- 
tration of the sodium in the plasma which is of 
the greatest importance in regard to the cel- 
lular content of water. In addition to the basic 
cardiac effect, such individuals are unquestion- 
ably made further susceptible to this complica- 
tion when their preoperative treatment has in- 
cluded a low sodium diet and mercurial 
diuretics. Rigorous limitation of fluid adminis- 
tration during and after surgery in these people 
is imperative. 

Of considerable theoretical interest and occa- 
sional practical importance is the clinical effect 
which results when the serum sodium is forced 
above its normal level. This situation is fortu- 
nately rare since the normal mechanisms for 
regulation of the extracellular fluid concentra- 
tion rather strongly resist any elevation of the 
serum sodium. There are two surgical situa- 
tions, however, wherein such hypernatremia 
may occasionally be observed. One is in certain 
types of central nervous system damage, namely, 
those involving hypothalamus and the frontal 
lobes. The second follows certain types of dam- 
age to the kidneys. Although the latter was 
originally described in connection with sulfa- 
thiazole poisoning, it is now recognized that 
it can follow almost any type of acute renal 
damage, and, as more and more cases are 


studied, it would appear that a transient hyper- 
natremia of mild degree is a rather common 
part of the sequence of rccoxx'ry from acute 
renal injury. The underlying mechanism re- 
sponsible for clinical signs under these circum- 
stances is clearly a movement of w'atcr from 
the intracellular to the extracellular compart- 
ment in response to the elevation of the serum 
sodium. Here again, the cells of the central 
nervous system are particularly sensitive and 
the signs which result arc those of profound 
stupor, central nervous system clejircssion, liy- 
perpyrexia and, occasionally, athetoid and 
choreiform movements of the extremities. /\1- 
though little is known of the treatment of this 
disorder, it is a]) parent that whenever feasible 
complete avoidance of parenteral salt adminis- 
tration must be enforced with administrations 
of as large amounts of salt-free glucose solution 
as the patient can tolerate. 

Management of Acute Renal Insufficiency. 
Acute renal shut-down, being a rather com- 
mon complication of surgery, is one that every 
surgeon must be prepared to meet. The exact- 
ing nature of this problem reminds one that in 
most situations gross di.se repancics from the 
ideal fluid and electrolyte management are com- 
pensated for by the kidney whose regulatory 
]X)wers arc normally able to correct the errors 
of the clinician. In the absence of renal func- 
tion, however, fluid therapy must be extraor- 
dinarily precise for e\^'ry measure that is taken 
is reflected in the actual composition of the 
interior of the body. 

Although the reactions caused by incom- 
patible transfusion and prolonged periods of 
shock appear to be the cause of many cases of 
postsurgical or post-traumatic anuria, it must 
he admitted that many instances of such acute 
renal failure are ascribable to no single cause. 
It would appear, however, that in renal shut- 
down which does not result clearly from trans- 
fusion reactions, or other toxic agents, the com- 
mon factor is reduction of effective blood supply 
to the kidney. This may occur even when re- 
duction of the systemic blood pressure does not 
take place. Ischemia resulting in varying de- 
grees of necrosis of renal cells is histologically 
most frequently demonstrable in the distal tubu- 
lar epithelium. It is not at all clear, however, 
that those cells which can be seen to be dam- 
aged under a microscope are the only ones 
which are functionally impaired. The impor- 
tant fact is that if one follows the changes 



141 


Management of Fluid and Electrolytes in Surgical Practice 


in the damaged tubular epithelium, regenera- 
tion begins to occur between eight to fourteen 
days, and if the patients can be maintained in 
adequate fluid and metabolic equilibrium until 
that time, the majority can survive such periods 
of severe reduction in renal function. In the 
older literature, many instances of survival 
from periods of prolonged anuria were re- 
corded with little specific therapy. Unfortu- 
nately, when the use of parenteral fluids and 
electrolytes became widespread, the overzealous 
use of these agents resulted in the death of the 
majority of such patients. In recent years, a 
number of methods of artificial dialysis, the 
most successful being the Kolff artificial kid- 
ney, have come into use. Although these have 
a definite field of usefulness, the mainstay of 
treatment in the majority of patients with 
acute renal insufficiency is cautious and quan- 
titative fluid management. 

Anuria is arbitrarily defined as a urine out- 
put of less than 100 cc. in twenty -four hour 
periods. Characteristically, anuric patients have 
certain electrolyte deviations. In cases as they 
are ordinarily seen, both sodium and chloride 
in the extracellular fluid tend to be low (Fig. 
5). The main reason for this is that no matter 
how early the condition is recognized the pa- 
tient will have been given, or have ingested, 
water which has not been excreted. Conse- 
quently, a certain amount of over hydration 
exists from the start. In chronic renal insuf- 
ficiency, the inability of the kidney to con- 
serve sodium may play a role in the genesis of 
this diluted picture but is obviously of no im- 
portance in the completely anuric individual. 
In addition to the sodium and chloride, bicar- 
bonate is almost uniformly reduced. This indi- 
cates metabolic acidosis resulting from a com- 
bination of the depressed serum sodium level 
and an abnormal accumulation of anionic 
metabolites such as sulfate, phosphate and or- 
ganic acids. 

Fluid administration must be limited to that 
which is required to replace insensible losses. 
In addition to accurate recording of intake and 
output, daily determination of the body weight 
is absolutely necessary because of the great 
variation in insensible water loss among indi- 
viduals. It will be found by 6uch measurements 
that most of these patients should be given 
only from 500 to 750 cc. of fluid daily to re- 
place their water loss. Very rarely are more 
than 1000 cc. required. If suction tubes or 


Transfusion Kidney 
Anuria 

mEq/l B.UN.= I28 



Figure 5. Effect on serum electrolytes of acute 
anuria. Note reduction in total base as well as chloride 
and bicarbonate and extension of anions normally ex- 
creted by the kidney (phosphate, sulfate and organic 
acids). 

fistulae are present, the loss through these 
channels must be added to the above. Within 
reason, it appears definitely valuable to take 
what measures are necessary to maintain as 
normal as possible a composition of the extra- 
cellular fluid. This should be done only when 
it is possible to add the necessary components 
without exceeding the rigid quota of fluid es- 
tablished by the insensible water loss. There- 
fore, particularly when the sodium level is low, 
it is advantageous to use small amounts of 
sodium bicarbonate or sodium lactate to correct 
the metabolic acidosis. Similarly, when sodium 
and chloride deficiency clearly exist and are 
not the result of overhydration, appropriate 
amounts of these ions should be given. Fre- 
quently, this must be done by resorting to hy- 
pertonic solutions in order not to increase over- 
all fluid intake. The only deviation which can- 
not be dealt with in this manner is a mounting 
potassium level, an unfortunate but frequent 
complication of prolonged anuria. Within 
limits this can be prevented by the avoidance 
of oral and parenteral administration of potas- 
sium ion and omitting blood transfusions when 



142 ampler 5. Principles of Pre- and Postoperative Care 


they are not absolutely necessary. Very transi- 
lorv reduction in scrum potassium level can be 
achieved by gi\'ing glucose intravenously with 
or without insulin, which causes a small 
amount of the plasma potassium to be trans- 
ferred to the interior of the cell in association 
with glycogen. Persistent increase in potassium 
level o\'cr the level of 7 milliequivalents per 
liter must be specifically dealt with and to date 
the only effective mechanism for doing this is 
perfusion with an artificial type of dializer. 

With this type of treatment many instances 
of anuria will be carried to spontaneous 
diuresis within seven to ten days. At this point 
careful scrutiny of the chemical picture is also 
required, for all moieties of renal function do 
not recover simultaneously. In some instances, 
the initial diuresis will include large amounts 
of all the extracellular electrolytes and in the 
absence of complete tubular regeneration the 
urine may very closely approximate glomerular 
filtrate. Under the latter circumstances, very 
large amounts of water and electrolytes may 
be required to avoid the creation of over- 
whelming extracellular fluid deficiency or 

serious hypochloremia and hyponatremia. 

Under other circumstances, sodium and 

chloride may not be excreted at all in the urine 
hut only large amounts of water may be put out 
during the period of diuresis. Here hyper- 
natremia may develop with its attendant effects 
on the central nervous system. When this 

situation is recognized, obviously only salt-free 
fluids should be given and these frequently in 
very large amounts. It is necessary, therefore, 
to follow patients carefully not only during the 
period of anuria hut through the phase of 
diuresis. 


READING REFERENCES 

Albright, E.: “Cusliiii'’ Syndrome',” PiUholiii'ical 
Physiology, Its Rciationship to the Adivno gonital 
Syndrome and Its Crmncction uitli the Problem of 
the Reaetion of the Body to Injurious Agents. 1 larvev 
Lcct.3S;l23, 1942-4A 

Collet, F. A„ Campbell, K. N., \''aughan, 11. 11,, 
lob, L. V., and Moyer, C. A.: Posto|icrativc Salt 
Intolerance. Ann. Surg. 119:5.33, 1444. 

Cutlibertson, D. P.: Post-SliiK'k MelalHilie Response. 
Lancet 1:933, 1942, 

Darrow, D. C.: Body Fluid Plis'siology; the Role of 
Potassium in Clinical Disturbances of Bod)' Water 
and Electrolyte. New England J. Med. 242:978, 
1950. 

Darrow, 1). €., and Yannet, If.: The Changes in the 
Distribution of Body Water Accompanying Increase 
and Decrease in H.\'tracellular Electrolyte, J, Clin, 
Investigation 14:226, 1935. 

Gamble, J. L.: E.xtracellular Fluid— Cbemical Anat- 
omy, Physiology and Patholog)'. Cambridge, Mass., 
Harvard University Press, 1954. 

Howard, J. £., and Bigham, R, S., Jr.; Transactions of 
Tenth Conference on Metabolic Aspects of Con- 
valescence. Josiah Maev, Jt. Foundation (1945). 

Moore, F, 1)., and Ball.'M. R.: The Mclaholic Re- 
sponse to Surgery'. Springfield, 111., Charles C 
Thomas, Publisher, 1952. 

Maire, F. U.: Tlie Low Sodium Sviidromes of Sur- 
gery, J.A.M.A. 154:379, 1954. 

Moyer, C. A.: Fluid Balance, a Clinical Manual. 
Chicago. The Year Book Publishers, Inc., 1952. 

Muirhead, E. E., and Hill, J. M.: Treatment of Acute 
Renal Insufficiency. Surg., Gynec. & Obst. X7;445, 
1948. 

Randall, H, T.: Water and Electrolyte Balance in 
Surgery. Surg. Clin. North America 32:2:445, 1952. 

Setye, H.: Stress. Montreal, Acta, Inc., 1950. 

Wangensteen, 0. II.; Controlled Administration of 
Fluid to Surgical Patients Including Description (if 
Gravimetric Methods of Determining Status of Hy- 
dration and Blood Loss during Operation. Minnesota 
Med. 25:783, 1942. 

Zimmermann, B., and Wangensteen, 0. 1!,: Obsem- 
tions on Water Intoxication in Surgical Patients. 
Surgery 31:654, 1952. 



6 


Endocrinology and Metabolism in 
Surgical Care 

By FRANCIS D. MOORE, M,D, and RICHARD W. STEENBURG, M.D, 

Francis Daniels jMoore is a Harvard College and Medical School graduate who 
was born in Illinois. He %ms trained in surgery at the Massachusetts General Hos- 
pital He now holds the Moseley Chair of Surgery at Harvard Medical School and is 
the Surgeon-in-Chief of the Peter Bent Brigham Hospital Dr. Moore represents the 
group of surgeons of today who have applied a basic knowledge of biochemistry and 
metabolism to surgical problems. 

Richard Wesley Steenburg, a Nebraskan by births was educated at Stanford Uni- 
versify^ Harvard College and Harvard Medical School He has served as a surgical 
research fellow and is now a member of the resident staff of the Peter Bent Brigham 
Hospital 


INTRODUCTION 

During the past two decades, it has been pos- 
sible to map out in some detail a variety of 
endocrine alterations with associated metabolic 
changes which are characteristic of surgical 
convalescence, just as other metabolic and en- 
docrine sequences are characteristic of puberty, 
pregnancy or senility. Viewed in this light, sur- 
gical convalescence is a bodily adjustment to a 
new set of external and internal circumstances. 
The circumstances involved are those of acute 
disease and tissue trauma; the complex response 
results in healing of the wound and restoration 
of the individual to normal physical, economic 
and emotional activity. These changes of con- 
valescent endocrinology and metabolism are 
common to all fields of surgery and all areas 
of the human body, although the nature of 
the wound itself is of great importance in de- 
termining the depth and duration of the 
metabolic response. The metabolic changes pro- 
duced by a fracture, for example, are different 
from those produced by a burn, even though 
certain of the endocrine responses have much 


in common. An understanding of this metab- 
olism is the basis for effective care in surgery. 

The role of the adrenal glands in general 
surgical physiology is an important one because 
of the many regulatory functions which the 
adrenal steroids play in tissue metabolism. An 
account of endocrine changes alone brings 
little of usefulness to the practicing surgeon, 
no matter how great his interest, because it is 
the associated metabolic changes and their 
pathologic variants in his sick patients which 
are really of critical practical importance. Al- 
though the precise relationship between sur- 
gical endocrinology and the metabolic response 
is unknown at this time, the two occur to- 
gether and are best described together as a 
basis for the understanding of normal con- 
valescence and, through this, the abnormal. 

It is our purpose to outline the underlying 
principles which should guide daily sur- 
gical care, according to the chronological se- 
quence of convalescence. First are described 
the early changes after injury, then the period 
of spontaneous regrowth, and finally certain 


Page 143 



144 


Chapter 6. Endocrinology and Metabolisnr in Surgical Care 


aspects of late convalescence. A few of the 
major abnormalities and variations in these 
convalescent patterns arc then discussed. 

CATABOLISM: THE EARLY PERIOD OF 
STRESS AFTER INJURY 

An intraserous operation involving extensive 
dissection and anastomosis, such as gastrectomy 
or combined abdominoperineal resection, trans- 
peri toneal nephrectomy, colectomy, splenectomy 
or lobectomy may be considered as the proto- 
type "moderate trauma,” a trauma occupying a 
mid-position in the scale of injury to which the 
flesh falls heir. The subsequent description is 
based on such a mid-scale trauma as a “normal” 
with which other patterns of convalescence 
may be compared. 

Endocrinology. Adrenal Cortex. Endo- 
crine changes are evident very close to the time 
of the incision. In occasional instances, the low- 
ering of eosinophil count prior to surgery may 
be evidence of preoperative adrenocortical 
stimulation by apprehension or medication. 
Shortly after the induction of an ether anes- 
thesia, the eosinophil count (often after a 
transient rise) drops to zero, or near zero, and 
remains there for from two to five days. Coin- 
cident with this sudden drop in eosinophil 
count is a rise in the free serum 17-hydroxycor- 
ticoids from normal values of 10 to 20 micro- 
grams per cent to stimulated values in the 
range of 40 to 80 micrograms per cent, depend- 
ing on the nature of the anesthetic and the 
magnitude of the trauma. The fall in the 
eosinophil count is usually complete two or 
three hours after the induction of anesthesia. 
The peak in serum steroid is often not reached 
for an additional three or four hours, character- 
istically in mid-afternoon of the day of a 
morning operation. These two changes are se- 
lected from amongst a host of measurable in- 
dices, as indicating an increased secretion of 
adrenal steroids of the compound E-F group, 
represented largely by compound F, or hydro- 
cortisone, in normal human adrenal secretion. 

Because of this increased secretion of adrenal 
substances, there is an increased excretion in 
the urine of steroids which have largely been 
conjugated in the liver as glucuronides. The 
duration of this adrenal secretorv increase varies, 
but normally the blood steroids have returned 
to normal by the next day. lire eosinophil 
count may remain near zero for from three to 
five days before gradually swinging upwards. 


The increased excretion ol steroid hormones in 
the urine may continue for two or three days 
after the blood level has returned to or near 
normal. This suggests that adrenal secretion is 
still increased but that the meehanisms for 
clearing the blood (hepatic) and excreting the 
conjugates (kidney) have increased their rate 
so that they can keep up with the increased 
adrenal production. 

Although many endocrine charigcs are in- 
volved in surgical endocrinology, more informa- 
tion is available on adrenal changes than any 
of the others. The teaching lor years has been 
that the adrenal secretes three classes of hor- 
mones (glucocorticoids, mineralocoiticoids and 
androgens) and that the urinary !7-ketoster()id 
excretion represents end-products of androgen 
output. We now know that neither of these 
time-honored contentions is accurate, flhe 
adrenal secretes a \'ariety of steroids, many of 
which possess in one molecule and to \'arving 
degrees several of the actions; glucose nitrogen 
activity, sodium activity and sex-honnonc ac- 
tivity, the latter being either estrogenic, andro- 
genic or progestational. Indeed, progesterone is 
one of the adrenal secretory products being 
an 1 T17-dcsoxycorticoid, and tnosl mineralo- 
corticoids including 1 l-clesoxycortieoslerone 
(DOCA) have progestational activity! 4’hc 
steroids which terminate their life in tlie body 
with a ketone group on carbon 17 (the 17- 
kctostcroids) arc not only those which start 
with this configuration, such as the testicular 
androgens and adrenal androgens, hut also a 
variety of other compounds including corti- 
sone and hydrocortisone which lose their car- 
bon 17-sidc-chains in the course of metabolism 
and have it replaced by a koto group, f)robably 
in the liver. The adrenal hormones arc inter- 
convertccl, inactivated by conjugation or reduc- 
tion, oxidized and excreted at varying rates, 
depending upon secretion, liver function and 
kidney function. Given a constant rate of 
secretion, sudden changes in inactivation rate 
could give the appearance of enhanced activity 
—and precisely this appears to happen at least 
to some extent after surgical trauma, in the 
course of which liver function is almost always 
impaired. 

For these reasons, one must view the meas- 
urements in blood or urine of a certain steroidal 
configuration as indicating crudely only a small 
fraction of the net result of a very comph^x 
endocrine change involving secretion, degrada- 
tion, interconversion and conjugation. The oc- 



Catabolism 


145 


currence of such sudden and massive changes 
in the 1 7-hydroxycorticoid fraction leaves little 
doubt that the smooth tenor of adrenal function 
is drastically altered by tissue trauma. 

The secretory impulse which follows surgery 
appears to invok'e hydrocortisone predomi- 
nantly, the concentration of this hormone being 
much larger than any of the others. The in- 
creased concentration of this substance in blood 
and urine may be measured by a colorimetric 
method specific for corticoids tvith a hydroxyl 
group on carbon 17 (compounds E, F and S), 
and it is such measurements which have been 
referred to in the foregoing account of post- 
operative changes. 

Mineral activity is not prominent in hydro- 
cortisone, though present. An extremely potent 
electrolyte-active steroid, aldosterone, is nor- 
mally secreted by the adrenal independent to 
some degree of ACTH changes. The increased 
tendency to retain salt after surgery sug- 
gests an increased secretion of this substance. 
This has not as yet been established and again 
we must recall that changes in inactivation or 
excretion could alter the peripheral metabolism, 
as well as changes in production. 

The pituitary and hypothalamus are the key- 
stones of this endocrine response, since it is 
through these agencies that the trauma initiates 
the endocrine response. The initial change is 
an increased secretion of ACTH by the 
pituitary, evidently in response to stimuli orig- 
inating in the periphery and mediated through 
the hypothalamus. 

Adrenal Medulla. Coincident with these 
measures of increased adrenal cortical activity 
after trauma are evidences of activity of other 
endocrine glands. Increased pulse rate and 
narrowing of pulse pressure with increased 
sweating and decreased capillary circulation 
in the skin are evidences of adrenal medullary 
activity. These signs are most marked if the 
patient is in severe pain, is very apprehensive, 
or approaches clinical shock due to reduced 
blood volume. In the absence of any of these 
circumstances, the adrenal medullary evidences 
may be quite minimal except for the effects 
of ether anesthesia which evidently is asso- 
ciated with a vexy marked production of epi- 
nephrine and related compounds by the 
adrenal medulla. 

Antidiuresis. A normal individual given 
an intravenous injection of a 5 per cent solu- 
tion of glucose in water rapidly increases his 
urine flow from normal rates of 1 ml. per min- 


ute to rates as high as 6 to 8 ml. per minute. 
Coincident with this, there is a drop in the 
urine osmolarity from normal values of 500 to 
800 milliosmols per liter down to values nearer 
200 milliosmols per liter, By dint of this 
water diuresis, the solute concentration of 
serum (as measured by sodium, protein or total 
osmolarity) undergoes no lasting change. Tliis 
is a normal diuresis in response to water in- 
fusion. After surgery, even of rather minor 
extent, this normal diuresis of a water load is 
markedly or completely inhibited. The same 
infusion given under these circumstances pro- 
duces virtually no increase in urine volume or 
decrease in urine osmolarity. The water is re- 
tained with a resultant fall of serum osmolarity, 
from normal values of 280 to 290 milliosmols 
per liter down to values around 260. 

These are the observations in surgical pa- 
tients which have demonstrated the occurrence 
of ‘'postoperative antidiuresis.’' This is clearly 
of importance in surgical care and it appears 
to be another evidence of endocrine activity 
after trauma. Presumably, this effect is pro- 
duced by stimulation of the posterior pituitary 
gland to elaborate its antidiuretic hormone. 
Although this has not been proved, there has 
been measured by several workers an increase 
in the urinary excretion of antidiuretic sub- 
stances in surgical patients. 

Other Endocrines. After trauma there is 
an increase in oxygen utilization and an evident 
increase in the rate of oxidation of tissue sub- 
strates, particularly fat and protein. This might 
appear to be thyroidal in origin. It is certain that 
a normal thyroid is essential for a normal 
trauma response; patients with hypothyroidism 
are notoriously intolerant to surgical trauma and 
medication unless they have been rendered 
euthyroid by the administration of thyroid 
substances. Yet there is no incontrovertible evi- 
dence that systematic alterations in thyroid 
function follow trauma, and there is a wide 
variety of disease processes which increase 
oxygen consumption without demonstrable 
thyroid imbalance. 

There is clinical evidence that gonadal func- 
tion is decreased after injury. In the female, 
amenorrhea occurs after extensive trauma or 
surgery and there is often a male-type hair 
growth observed in women who have very ex- 
tensive injury such as bums. That this is not 
solely a nutritional factor is suggested by the 
observation that weight loss due to other forms 
of disease is not necessarily associated with 



146 


Chapter 6. Endocrinology and Metabolisn^ in Surgical Care 


such reversion to a neutral sexual pattern. Re- 
productive activity resumes some time during 
or after the phase of positive nitrogen bal- 
ance. 

Systematic changes in the function of the 
pancreatic islets and the parathyroids have not 
been observed after trauma. The mobilization 
of liver glycogen and formation of glucose 
from protein result in an elevated blood glucose 
after injury, effects hastened by adrenal medul- 
lary and adrenal cortical activity. When im- 
mobilization is prolonged, there is a marked loss 
of body calcium. 

The Wownd. During the early period of 
post-injury metabolism, the primarily sutured 
wound has little tensile strength. The accumu- 
lation of leukocytes and of extracellular fluid 
containing the compounds found in plasma 
(many of which are mobilized from muscle) 
characterizes this period. If dead tissue and 
virulent organisms do not abound, the wound 
then commences to gain tensile strength by 
the conversion of protein precursors into the 
intercellular structure of collagen. Vitamin C 
is a requisite for this reaction to occur. 

Metabolism. Protein and Nitrogen. Pro- 
tein metabolism is profoundly affected by 
trauma; observations of this phenomenon 
formed the earliest metabolic studies of trauma 
and there is a wealth of information available in 
the literature. The characteristic change con- 
sists of an increased absolute urinary nitrogen 
excretion rate despite diminished intake, with 
negative balance as a result. 

The normal adult male ingests approximately 
10 to 12 gm. of nitrogen a day and excretes 
a like amount, all but 1 gm. of which is ex- 
creted in the urine. He is, therefore, referred 
to as in zero balance of nitrogen. After in- 
jury, even though the nitrogen intake may fall 
to zero, as it so characteristically does, the ex- 
cretion is increased and, after major injury, 
nitrogen excretion rates in the urine of 12 to 
15 gm. a day are regularly observed. After 
more extensive injury, the urinary nitrogen 
loss may range as high as 25 gm. per day. This 
amount of nitrogen (20 gm.) lost daily over a 
period of four days represents the catabolism 
of about 500 gm. of protein— an extreme figure 
but not an unusual one. This much protein 
would form the cellular mass of approximately 
2000 gm. of wet lean tissue such as muscle. 
This large amount of tissue which is catabolized 
after major injury is mentioned to emphasize 
that there can be little mystery about its 


source. Except in most remarkable circum- 
stances, the wound itself is a source of only 
a small fraction of this nitrogen. (Tanges in 
size of the liver, heart, lungs, kidney or other 
viscera would Ivdvc to he massive, of the order 
t)f magnitude of 50 ju'r cent rccluction in size, 
in order to account lor c\'cn a Iracliofr of this 
nitrogen. It is vv'cll known that these organs 
do not diminish in size altci trauma; indeed 
they are -dpt to increase. This lea\'c‘s the skele- 
tal muscle, which forms the great mass of pro- 
tein solids in the body composition, as the 
source of the nitrogen lost after trauma. .Alter 
major injury, the patient fecLs u'cak anti if his 
injury has been considerable, as in a hum 
or in a war wound, he is extremely v\'cak by 
two or three weeks after the injury. This weak- 
ness is correlated with a visible and easily 
measurable rccluction in size of major muscle 
masses. It is apparent, tliercforc, that trauma 
excites the mobilization of small -molecular' 
weight nitrogen cojiipoiinds from the jirotein 
of muscle, by an intense catabolic destruction. 
These nitrogen compounds are excreted in the 
urine, most of them having been coin'crtcd 
into urea en route from muscle to urine. There 
are interesting and important cTanges in t'x- 
cretion of certain other small nitrogen com- 
pounds such as the amino acids, but these tirc 
of quantitative minor import thougli of great 
significance in providing raw material for 
wound synthesis. 

Potassium. A number of electrolytes exist 
in the cell with protein and the whole is 
bathed in an amount of water which comprises 
approximately 73 per cent of the weight of 
the cellular mass. The intracellular electrolytes 
are chiefly potassium, phosphate, sulfate, cal- 
cium and magnesium and of these substances, 
the most information is available with respect 
to potassium. After a surgical operation, potas- 
sium excretion is increased in the urine. The 
nonnal adult consumes about 100 niEq. of po- 
tassium each day and excretes a like amount 
in the urine. If his intake is suddenly stopped, 
he excretes about 40 or 50 mEq. in the urine 
the first clay and then over a period of days, or 
weeks, his urinary potassium excretion is gradu- 
ally reduced to a minimum figure of about 10 
mEq. per day. After major surger}'~with no 
potassium intake— the urinary excretion ranges 
from 70 to 100 mEq. the first day and for tire 
next two or three days the potassium excretion 
continues to be greater than one would expect 
in starvation alone, The amount of potassium 



Catabolism 


147 


lost from the body in the first four <ia\'s is 
from 150 to 300 mEq. as an average. For the 
most part, this potassium may be considered 
as coming out of cells along with nitrogen, as 
the cellular structure is destroyed or atrophied 
following trauma. In most instances, however, 
there is some “excess" potassium excreted above 
that which would be expected to come out with 
the nitrogen alone. Potassium and nitrogen exist 
in muscle in a fairly fixed ratio at 27 to 3.0 
mEq. potassium per gram of nitrogen. After 
injury, the potassium is lost at a rather higher 
potassium-nitrogen ratio, and by the same token 
it starts to return to the cell somewhat sooner 
than nitrogen. This “excess" potassium is pre- 
sumably removed from the cell in exchange 
for hydrogen, or sodium ions, or both, and this 
abnormal state of affairs reverts to normal more 
rapidly than the resumption of true tissue 
anabolism. After this initial potassium loss, the 
body rapidly regains potassium as feeding is 
resumed. 

Sodium, Chloride. Both sodium and chlo- 
ride are conserved during the early phase after 
surgery. As a general rule, more sodium is re- 
tained than chloride; in terms of renal excre- 
tion the sodium conservation mechanism oper- 
ates more actively than that for chloride. On 
the day of operation, sodium excretion may 
continue, but at a reduced rate with amounts 
from 10 to 50 mEq. being lost in the urine, 
if no sodium is given. Then, in the next two 
or three days, sodium conservation becomes 
evident and the sodium excretion in the urine 
is reduced sharply to from 1 to 10 mEq. In 
more severe injury, particularly when there is 
an oligemic phase, the reduction in sodium ex- 
cretion may commence immediately. If sodium 
is given intravenously during this phase, there 
is an increase in sodium excretion over that 
observed when no sodium is given; the sodium 
excretion will not keep pace with the infusion, 
however, and a strongly positive sodium bal- 
ance will result. The duration of this sodium 
conservation phase is amongst the most variable 
features of post-traumatic metabolism. Usually, 
in well-nourished individuals undergoing major 
injury or surgery, sodium conservation starts 
rapidly and passes off in three or four days with 
a fairly clear-cut sodium diuresis, during which 
sodium excretion is increased. In individuals 
who are less well nourished, sodium conserva- 
tion may be a little slower to start but persists 
for a much longer time and diuresis may never 
he clear-cut. 


Serum Electrolytes. Coincident with these 
changes in metabolism early after trauma is a 
tendency for the serum sodium concentration to 
fall (to 130 to 135 mEq. per liter) and the 
potassium concentration to rise (to 4.8 to 5.3 
mEq. per liter). These tendencies appear to be 
paradoxical in ^iew of the opposite nature of 
the concomitant balance changes. The explana- 
tion of the concentration changes is unknown 
and in normal circumstances it is of no more 
than passing interest clinically; but in the 
presence of depletion, shock or heart disease 
these changes may become tremendously exag- 
gerated and be a threat to survival. 

Body Weight. Body weight tends to fall 
sharply after trauma, particularly if the 
trauma is in a previously well-nourished pa- 
tient, and if there is not a large area of edema 
accumulation, as in a burn or a crush. If 
traumatic edema accumulates, the weight loss 
may be obliterated or replaced by a gain owing 
to the accumulation of water and salt. When 
this fluid is subsequently diuresed, the patient’s 
weight will fall sharply down to the level which 
would have been attained had catabolism of 
fat and lean tissue been the only occurrences. 
Following moderately severe trauma in well- 
nourished people, one may expect a loss of 
approximately 3 kg. of weight in the first five 
days. In more extensive injury, the loss may 
be two or three times as fast. This lost tissue 
is about one-half fat (the increased oxidation 
of which is one of the characteristic changes of 
convalescence) and one-half lean tissue (mus- 
cle) which is the source of nitrogen in the 
urine as already mentioned. This weight loss 
rate is gradually reduced, reaching a plateau, 
and later giving way to the weight-gain of 
convalescent anabolism. 

Calories, Ghicose. The caloric intake im- 
mediately after trauma is usually reduced to 
zero for the obvious reason that the patient will 
not, cannot, or should not eat. The glucose ad- 
ministered intravenously provides a small sup- 
ply of readily available calories which may be 
the only calories supplied until oral intake 
again begins. During the first five clays after 
trauma, there is little to suggest that forcing 
further calories affects the patient favorably. 
This is in sharp contrast to the situation later 
on in convalescence when the administration 
of exogenous calories is of vital importance for 
recovery. 

The blood sugar quite regularly rises after 
trauma and there is some tendency for glyco- 



148 


Chapter 6. Endocrinology and Metabolism in Surgical Care 


suria and decreased glucose tolerance. This 
"anti-insulin effect” may be clue to the in- 
creased amount of steroid circulating in the 
blood, to the mobilization of liver glycogen, or 
to the sudden production of carbohydrate by 
the degradation of fat or protein. 

Semin Protein. During this early phase 
after trauma, the serum protein concentration 
does not change markedly. If there is acute de- 
hydration due to loss of water or water with 
salt, the serum protein may rise along with 
the hematocrit reading. If there is accumulation 
of water and salt due to over-administration of 
these substances, the serum protein will lall. 
Such excesses of water and salt are the com- 
monest causes of hypoproteinemia in surgical 
patients. 

CSioical Management. After moderate 
trauma in well-nourished individuals, the 
metabolic management of this phase of con- 
valescence presents few problems. 

The most important therapeutic step is that 
of a well-performed operation, accurately di- 
rected to the major disease from which the pa- 
tient suffers and carried out in such a way as 
to impose on the wound a minimum load of 
contaminated and dead tissue and to avoid 
hypotension, oliguria, distension or extrarenal 
loss. All of these distort the normal convalescent 
sequence and divert the resources of the or- 
ganism. 

If the patients oral intake is interrupted for 
only one day, he will get along well without 
any intravenous or other parenteral therapy. If 
more extensive trauma has occurred, the ad- 
ministration of intravenous fluids for a day or 
two may forestall dehydration and provide 
water until intake starts. The administration of 
50 to 150 gm. of carbohydrate by vein in these 
first few days forms an Inevitable accompani- 
ment of water administration and provides a 
small caloric ration. Enough water should be 
administered to cover the losses from the body 
by lungs, skin and urine, allowing for urine 
output of between 350 and 750 cc. on the first 
day and somewhat more on subsequent 
days. 

When there are no extrarenal losses of water 
and electrolyte, the administration of electro- 
lyte is usually unnecessary during the few 
days before oral diet is recommended. Small 
amounts of electrolyte do no harm, however, 
and many prefer to give enough to allow for 
small losses. As an example, if enough potas- 
sium, sodium and chloride are given to allow 


for 40 mkq. or each in the urine during the 
early postoperatixe days, this purpose will be 
accomplished without excess. Under no cir- 
cumstances should the patient be given excesses 
of electrolyte or of water since in eitlicr case 
retention will result, with the production of 
scrum dilution or hypoproteinemia or both. 
Furthermore, quantitative replacement of all 
urinary losses of sodium and chloride should 
not be attempted. 

When trauma has been extensiwg and is ac- 
companied by sepsis, conUniicci interruption 
of oral intake, high fever, continuing blood 
loss, wound edema, extrarenal loss or renal 
disease, the management of this phase of con- 
valescence requires extremely accurate^ and 
considerably more complex thcrapv'. llie prin- 
ciples involved are based firmly on the endo- 
crine and metabolic facts mentioned above for 
normal convalescence. The administration of 
fluids, electrolyte or blood should he carefully 
balanced to equal the loss, recalling that renal 
excretory patterns arc keyed to conserv'ation of 
extracellular water and salt. When the inter- 
ruption of oral intake can be expected to last 
for more than three clays, it is advisable to 
commence potassium administration by vein 
on the clay of, or the day following, surgery, 
using 40 mEq. per clay as a general rule to 
cover renal losses and larger amounts when 
extrarenal loss is prominent. 

ANABOLISM: THE PERIOD OF REGROWTH 

Endocrinology. As mentioned previously, 
the initial hurst of adrenal steroid activity 
which Follows trauma is rather short-lived, at 
least as judged by the increase in scrum and 
urine steroid concentration. The eosinophil 
count rapidly returns to normal, often reach' 
ing values considerably higher than observed 
preoperatively. It should return to normal by 
the fifth day after moderate trauma. Evidences 
of a posterior pituitary-like effect in the stress 
phase immediately after injury were found in 
the tendency to retain ingested or infused 
water. This tendency passes off and the pa- 
tient's metabolism of water returns to normal 
within a day or two unless complicating sys- 
temic or surgical factors are present. 

The Wound. In a clean primary wound of 
the type considered as the 'norm" here, the 
resumption in tensile strength occurs during 
the sharp upswing in nitrogen metabolism de- 
scribed below. This coincidence is lacking in 



Anabolism 


149 


more complex settings, however, and we esti- 
mate that on a mixed general surgical ser\’ice 
caring for trauma as well as elective surgery, 
about two-thirds of the wounds gain their ten- 
sile strength during continued nitrogen negativ- 
ity. Resumption of tensile strength is the result 
of fibroblastic activity and the formation of 
intercellular collagen which later becomes in- 
creased in the mature scar. The wound at 
seven days is a thin line appearing much as it 
did when originally sutured; at five to seven 
weeks it is a red, raised, thickened cicatrix. 

Metabolism. Although the steroidal re- 
sponse is usually short-lived, the metabolic 
change apparently initiated by it may outlast it 
by many days. In the moderate mid-scale trauma 
we are using as a prototype, the nitrogen re- 
versal often occurs within a day or two after 
subsidence of the adrenal discharge. In other 
circumstances, particularly in burns and frac- 
tures, as described subsequently, the associa- 
tion is less close. In any case, at some time after 
this release from steroidal influences, and only 
after its release, there occur tw^o metabolic 
events which symbolize the changing metab- 
olism of recovery. 

The first is a reduction in the urinary nitro- 
gen excretion rate. It is the occurrence of this 
reduction in urinary nitrogen excretion rate, 
together with a rise in eosinophils and a fall in 
urine steroid excretion, which has caused this 
early reversion towards more normal metab- 
olism to be called ‘'the corticoid-wnthdrawal 
phase. When the events happen together, the 
picture closely resembles that produced w^hen 
large doses of ACTH or cortisone are with- 
drawn from a normal individual. The urinary 
nitrogen excretion rate is suddenly reduced 
from rates of 14 to 20 gm. a day down to rates 
of from 5 to 7 gm. a day, over a period of 
one to two days. This indicates a sweeping 
change in nitrogen metabolism and protein 
dynamics, and if intake now rises with the re- 
sumption of eating, the patient rapidly assumes 
a positive nitrogen balance. 

The second event is a release of water and 
salt from the early post-traumatic conservation. 
Urine sodium concentrations rise and the ex- 
cretion of water loads is prompt and more 
clearly related to serum osmolarity. In some 
instances, these events constitute a clear-cut 
diuresis phase. In other cases, the changes are 
delayed and less clear-cut though of equal im- 
portance in signalizing the normal progress of 
convalescence. 


The positive nitrogen balance period which 
now ensues has been called *'the spontaneous 
anabolic phase of convalescence'’ and is a 
period of surpassing importance to the recovery 
of the individual. If the patient does not go 
into positive nitrogen balance, he will not re- 
gain muscular mass and strength and he wnll 
not recover. In such an event, the dynamic 
progress of cont^alescence may be thought of 
as "stalled.” The patient will develop chronic 
weakness and apathy, will not permit mobiliza- 
tion, weight loss will continue and the picture 
of convalescent failure will ensue, so common 
in association with late burns, sepsis and starva- 
tion. The rate at which protein is synthesized 
during anabolism averages in the neighborhood 
of 3 to 5 gm. of nitrogen per 70 kg. body weight 
per day. Instances have been reported in which 
spontaneous anabolism persisted for several 
weeks at a somewhat higher rate, even as high 
as 8 gm. of nitrogen per 70 kg. per day, an 
unusually rapid rate. 

The relationship of nitrogen metabolism to 
the recovery of the patient, on the one hand, 
and to the healing of the w^ound on the other, 
has been the source of much misunderstanding. 
There has been an impression that the loss of 
nitrogen in the early phase of convalescence 
is harmful to the patient and should be com- 
bated. If the individual has long been depleted 
by chronic disease, a strongly negative nitrogen 
balance (such as that produced by sepsis) is 
unquestionably deleterious, as further acute 
tissue wasting superimposed on chronic starva- 
tion results in visceral damage, particularly a 
fatty liver. In the well nourished, the brisk 
loss of nitrogen which follows trauma is usu- 
ally correlated with a satisfactory convalescence; 
although the patient might be “better off” if 
he did not lose this nitrogen, such has never 
been proved. By large intravenous loads of 
nitrogen (as protein hydrolysate) and glucose, 
the total losses may be reduced, but not the 
excretion rate which is further increased; bene- 
fit to the patient by such procedures is not 
readily demonstrable. Much more important 
in the consideration of nitrogen metabolism 
is the positive balance of later convalescence. 
While we may view the initial nitrogen loss 
with some tolerance, not knowing of any dele- 
terious results, we may take no such relaxed 
view towards failure in subsequent anabolism. 
Nitrogen gain and protein synthesis are abso- 
lutely essential for recovery. Without them the 
patient cannot return to a position of social 



150 Chapter 6. Endocrinology and Metabolism in Surgical Care 


usefulness, reproductive activity or the enjoy- 
ment of life. He will heal his wound— but there 
his achievements will cease. 

As to the relation of nitrogen balance to 
wound healing, one commonly hears the state- 
ment that wounds will not heal unless the 
patient goes into positive nitrogen balance. This 
is not the case. Most wounds heal readily dur- 
ing a negative nitrogen balance and it is a 
eommonplace after very extensive injury, or 
surgery, for the wound to heal to a state of 
tensile strength which penults removal of the 
sutures and the resumption of function of the 
operated part (intestinal tract, for instance) 
while the patient is still in negath^c nitrogen 
balance. This is not a rarity; it is a daily occur- 
rence. It has been hypothecated that the mo- 
bilization of nitrogen from body stores has as 
one ol its natural purposes the provision of 
small-molecular-weight nitrogen compounds as 
building blocks to provide the tissue which 
heals the wound. Such a view is merely an 
interpretation of natural events but it is based 
on the fact that patients accomplish the initial 
phases of wound healing during the negative- 
nitrogen phase. The most egregious failure of 
wound healing (manifested by wound dehis- 
cence and the complete failure of fibrosis to 
occur) is not associated with an unusual degree 
of nitrogen loss. Indeed, it is somewhat com- 
moner in depleted individuals with cancer in 
whom the post-traumatic mobilization of endog- 
enous nitrogen is halting or scanty. And 
finally, as mentioned above, the later assump- 
tion of nitrogen anabolism achieves its im- 
portance not because of wound healing but 
because it permits the regrowth of muscie, re- 
sumption of norma] bodily strength, vigor and 
visceral function. 

Potassium balance becomes positive during 
this anabolic period, and potassium loading 
starts significantly prior to positive nitrogen 
balance in most instances as described above. 
It remains slightly positive throughout the 
phase of spontaneous anabolism. 

Weight loss slows down as the metabolic 
corner is rounded If adequate diet cannot 
begin, it persists at a slower rate. As diet 
begins, a slow upward trend commences. 

Clinical Management. If the patient will 
eat his food normally, the clinical management 
of this phase of convalescence poses no thera- 
peutic problem. Recognition of the underlying 
requirements for exogenous calories, and of the 
calorie-nitrogen ratios required, forms the basis 


for the rational treatment of suigieal coinailcs- 
ccncc. As mentioned al)()\'e, the pr()\'ision of 
large caloric intakes is ol duhioiis benefit in 
the early period of catabolism. If giMai hv 
mouth and not absorbed, or \()mitc'cL the at- 
tempt to provide food early nun aetiialh’ be \ crv 
harmliil; there is no greater trageds than dis- 
tension or aspiration as a complication of un- 
necessary carl)’ dict-lorcing. Ihe nutritional 
objective in the card period is a scaphoid 
abdomen. 

/\s the patient rounds the cornea towards 
anabolism, peristalsis is resumed, lluac' is the 
anal excretion of swallowed air, aiul the 
time has come for diet. As 1 k‘ passers through 
the corticoid withdrawal pha.se and assumes 
a decreased urine nitrogen e.xerelion rater his 
body becomes extremely a^'id for erxogenous 
calorics. This is usually manifested by an 
increase in appetite, an interest in food anti 
resumption of normal ]Kiristaltic aetieity. 'fhe 
provision of exogenous cakiries now becomes 
essential to recovery and for tlie production of 
anabolism. 1 he calorics ideal! v should he 
supplied at the rate of 200 calories for each 
grain of assimilable nitrogen in the did. lint 
caloric-nitrogen ratios somewhat lower than 
this will support anabolism. 

In normal convalescence, alter surgery of 
the abdomen, thorax or extensive surgery of 
the extremities, the patient’s initial clidary 
effort during the corticoid withdrawal phase 
will give him nitrogen intakes in the range of 
3 to 7 gm, per day with calorie inlakc.s he 
tween 500 and 1500 calorics. /Viter two oi 
three days ol such an intake in the form of 
semisolid food, the patient will resume normal 
mixed diet, having a caloric intake of ap[)roxi' 
mately 2400 with a nitrogen intake in the 
range of 12 gm. In the case of a female, these 
figures arc all somewhat lower. 

During early anabolism, the patient’s weight 
will remain seemingly stationary at a level 
of from ] to 3 kg. below the preoperative 
weight. If very careful weight measurements 
are done daily, it will he found that weight 
is not stationary but is instead increasing very 
slowly at a rate determined by tfie positive 
nitrogen balance. Each gram of nitrogen loaded 
represents about 30 gm. of lean w^et tissue. For 
this reason a positive nitrogen balance of 5 
gm. per day, a higli rate of spontaneous ana- 
bolism, will result in the accumulation of only 
150 gm. of weight per clay. On such a basis 
it takes approximately a week to gain 1 kg. 



Fat Gain 


151 


Minor fluctuations in water balance and daih' 
happenchance differences in the time or con- 
dition of weighing will mash this small rate 
of gain unless special measures are taken to 
observe it. 

The most important abnormalities in con- 
\'alescence during this phase are continued 
sepsis, continued acti\’ity of parench\’matous 
\isceral disease, hemorrhage, and disorders of 
the intestinal tract, particularly diarrhea, ob- 
struction and paraktic ileus. All of these either 
increase the length of the period of catabolism, 
or postpone anabolism by lowering the ability 
of the gastrointestinal tract to resume its func- 
tions of ingestion and assimilation. 

FAT GAIN: LATE CONVALESCENCE 

Efidocimology. Little is known about the 
endocrinology of late convalescence. In the 
female, following extensit^e injury, surgery or 
burns, the male-type hair growth characteristic 
of the catabolic phase disappears and the 
female physical appearances return. Normal 
menses likewise return. The relationship of 
this gonadal renaissance to the other metabolic 
changes is uncertain. 

The Wound, During nitrogen anabolism 
the wound becomes a red, raised cicatrix, often 
somewhat sensitive to the touch. As the pa- 
tient passes into the later phase of convales- 
cence, the wound gradually broadens, softens, 
turns white and may become concave or 
wrinkled. The fine suture marks often are 
obliterated completely. 

Metabolism and Clinical Management 
During this time, the patient is obsen-’^ed to 
have returned to zero nitrogen balance if con- 
valescence has been normal and complete. Zero 
nitrogen balance is the normal state of the 
intact adult without gains or losses of weight. 

Despite zero balance of nitrogen, potassium 
and sodium, these being the elements which 
we have considered tlmoughout, the patient 
continues to gain weight. Measurements of 
total body water demonstrate that body water 
is constant during this period of weight gain, 
which indicates that the weight gain is due 
to accumulation of fat. When a patient has 
been chronically or severely ill, or has under- 
gone major surgery which has been followed 
by resumption of normal gastrointestinal func- 
tion, no elaborate methods are needed to deter- 
mine that fat is being gained during this time. 
Normal body contours are restored and clothes 
fit once again. 


The patient quite regularly lea\^es the hospi- 
tal during the spontaneous anabolic phase of 
con\’alescencc. For the body to regain fat nor- 
mally, the caloric intake must be significantly 
in excess of the daily energy output. If a 
patient is “borderline" as to calories, because 
of some disorder of the gastrointestinal tract 
(an example would be digesti\o disorders after 
subtotal gastrectomy), premature return to 
work will interfere with fat gain, the patient 
will appear to have had a normal convalescence 
in every other respect, but he will not regain 
his normal weight. Therefore, if an individual 
is not doing woll as regards appetite and caloric 
intake, he should be discouraged from assum- 
ing full activity until iveight has been restored. 

COMMON ABNORMALITIES OF 
CONVALESCENCE 

In this section will he mentioned briefly 
some of the common abnormalities of conva- 
lescence, the basis of which care lies in an 
understanding of the variations which they 
present from the normal endocrinology and 
metabolism of convalescence. In many instances 
such as renal failure, dehydration from extra- 
renal loss, fractures and sepsis, there are many 
details of pathogenesis, diagnosis and daily 
care which will not be mentioned. In all in- 
stances, the surgeon must realize that surgical 
judgment based upon a careful history, an 
accurate examination of the patient, intelligent 
selection and evaluation of laboratory work 
and x-ray examinations must take first place 
in his care. Sick surgical patients are problems 
in surgery first; their metabolic disorders may 
be of central importance in their recovery but 
without good surgical judgment, metabolic care 
is wasted. A patient wuth continued fever, con- 
tinued endocrine activity, continued high nitro- 
gen loss in the urine, continued conservation 
of sodium all due to a subdiaphragmatic ab- 
scess must have the abscess suspected, diagnosed 
and then drained. The adequacy of his meta- 
bolic care may determine survival in the end, 
but competent surgery comes first; if disease is 
overlooked or surgery clumsily performed, all 
else is in vain. By the same token, it avails 
little if body chemistry is normal while un- 
treated thrombo-embolism continues its lethal 
course unrecognized. Patients are helped by 
the application of surgical skill as a whole, of 
which metabolic care forms but one aspect. 

Extrarenal Losses. Since the first chemi- 
cal observations in surgical patients, the sub- 



152 Chapter 6. Endocrinology and Metabolism in Surgical Care 


ject of dehydration has occupied a great deal 
of attention in the surgical literature. Surgical 
dehydration most commonly occurs as a result 
of gastric or intestinal obstruction with vomit- 
ing of intestinal juices. Other causes are diar- 
rhea, intestinal and pancreatic fistulac. These 
represent extrarenal losses of fluid from the 
body, and the term is used to indicate those 
losses of fluid, salt and protein from the body 
which take place outside the kidney and out- 
side the normal renal regulatory mechanism. 
Occasionally, such collections as massive re- 
current pleural transudate, portal vein obstruc- 
tion with massive accumulation of exudate 
in the bowel, or appendiceal peritonitis pro- 
duce a picture of which dehydration forms a 
part. Under special circumstances, abnormali- 
ties of renal function may produce severe de- 
hydration through the kidneys themselves; the 
recovery phase of post-traumatic renal insuffi- 
ciency furnishes an example of unregulated 
w’'ater and salt loss through the kidney. With 
this exception, most dehydrating conditions 
in surgery involve extrarenal losses. 

The term ''dehydration” has come to be 
loosely used. Dehydration without salt loss is 
rare in surgery, being largely due to pulmonary 
loss in high ambient temperatures. When it 
occurs, it produces marked serum hypertonicity 
with hyperchloremia, hypernatremia and 
uremia. A similar picture is produced by in- 
judicious tube-feeding in the unconscious pa- 
tient. Prompt treatment with intravenous clcx- 
trose-in-water is most effective in pure dehydra- 
tion. The commoner situation is dehydration 
due to loss of water and salt, the latter largely 
extracellular. 

In no phase of surgery is the concept of 
"metabolic balance'’ more aptly brought to the 
bedside than in the management of the 
patient with large extrarenal losses. The ob- 
jective of the attending surgeon should be to 
achieve perfect balance. By this is not meant 
nitrogen balance. It is almost impossible in 
such a patient to achieve anything that even 
approaches positive nitrogen balance. In a 
patient with acute intestinal obstruction, losing 
liters of salt-rich fluid each day, it is folly to 
waste time over a consideration of calories or 
nitrogen balance. When the acute situation has 
been brought under control and the patient 
is again eating normally, his nitrogen balance 
will take care of itself. 

Rather, the concept of ''metabolic balance’’ 
in taking care of such patients is devoted to 


their balance of water and salt. The sails in- 
volved theoretically include tiic entire gamut 
of substances found in body fluids: sodium, 
chloride, potassium, magnesium, pliosphate, 
sulfate, ealcium, zinc and magnesium; these 
could all be mentioned but we have no way of 
measuring most ol these sul)stances. II the 
surgeon will denmte his unstinted attention to 
the balances of sodium, chloride and j)C)tas- 
sium, avoid the overadministration of water, 
maintain blood v'olume and colloid osmotic 
pressure, he can guide his patient through the 
most massive disorders of water and electrolyte 
metabolism and emerge success! ul. 

The first step is to measure the patient’s 
intake and oiiljuit with maxinuim accuracy. 
The measurement of fluid volumes should 
never be incomplete or inaccurate and on a 
surgical service equipped with such a simple 
device as a hollow^ container there is no excuse 
for ignorance as to the amount of fluid which 
has come out of the various orifices of the 
patient. If there are copious exudates in the 
dressings, vomitiis on the sheets and pillow 
cases, or diarrheal stools in the bed, such 
measurement becomes impossible hut an ob- 
servant nurse or doctor can make an educated 
estimate which is better than nothing. An 
estimate of the salt content of the collected 
discharges can he made on the basis of data 
documented in the literature or by direct anal- 
ysis. The following general rules hold for the 
gastrointestinal tract: 

Chloride — 

100 mEq./l. throughout. 

Sodium — 

High acid gastric juice: 15 mEq,/l. 

Low acid gastric juice: 60 mLq./l. 

Duodenal juice: 100-140 mEq./l. 

Pancreatic juice: 140-180 mEci./I. 

Potassium — 

Stomach: 15 mEq./L 

Small bowel: 15 mEq./l. except in .small 
bowel obstruction or ileostomy diarrhea 
in which thi.s may reach 70 niEq./l. 

Secondly, the patients weight should be 
followed closely. Weighing every clay, or at 
least three times a week, is essential. Rapid 
gains or losses are undesirable, indicating mas- 
sive fluid shifts. In the starving patient (un- 
stressed) a slow loss of about 150 gm. a clay, 
as fat is oxidized, is to be expected until oral 
intake and anabolism are restored. 

Thirdly, do not attempt daily urinary elec- 



Common Abnormalities of Convalescence 


trolyte loss replacement. It is a great mistake 
to restore to the patient the following day the 
amount of water or sodium lost in the urine 
the previous day. Renal excretory mechanisms 
for sodium, chloride and water are in part 
regulatory of extracellular volume and acid- 
base balance. The result of the readministra- 
tion of the sodium excreted in a diuresis can 
readily be imagined. If the patient is having 
very large urine volumes, it is also unnecessary 
to try to restore them each day unless there 
is one of the very rare renal tubular lesions 
present. In most surgical patients, high vol- 
umes or concentrations in the urine indicate 
important renal compensation for irregularities 
of intake. For this reason, we allow 40 mEq. of 
sodium, 40 of chloride, 40 of potassium and 
1 200 cc. of fluid each day for the urine output. 
This is a sound basis for treatment and will 
avoid serious error if renal function is normal. 
Insensible loss through skin and lungs totals 
about 750 cc. per day in a normal-sized adult 
male, 500 cc. for the female. If there is fever, 
hot weather or dyspnea, this may be tremen- 
dously increased. Dyspnea with fever is the 
most effective combination in increasing the 
extrarenal loss of water through the lungs, to 
figures as high as 2000 cc. per day. 

Armed with a knowledge of what has come 
out of the patient, and with an estimate of the 
extracellular concentrations remaining, the sur- 
geon can approach his daily intravenous ther- 
apy with accuracy and conviction. Under con- 
ditions of gastric obstruction, intestinal obstruc- 
tion, or diarrhea, the amount of fluids required 
per day may, of course, be massive, running as 
high as 8 to 10 liters in certain instances. By 
sharp contrast, the small, chronically ill female 
with congestive failure who has been vomiting 
from digitalis toxicity, may be overtreated if 
she receives 150 cc. of saline solution. Clarity 
of concept and accuracy of plan are essential! 

If the patient comes upon the scene with 
established dehydration, the situation is much 
more complicated because the static debt of 
the patient must be made up during the course 
of the first few days, during which maintenance 
is also essential. The most important rule in 
a large experience with such cases has been 
to avoid the temptation to make up the entire 
static debt too suddenly or on the first day. 
Patients become adjusted to lower levels of 
extracellular volume and they also become 
adjusted to some degree of serum hypotonicity. 
As has been said so aptly, the acutely unbal- 


anced patient should be “nudged,"' not “swept,"’ 
in the right direction. If the patient is an older 
individual with some degree of heart disease, 
the attempt to restore all past losses in one day 
may well result in a fatal outcome. As in all 
things in medicine, a careful history of intake 
and loss will set the stage for intelligent treat- 
ment. A weight gain for three to four days is 
to be expected as the debt is restored. This is 
the only exception to the basic rule of paren- 
teral therapy: avoid weight gain. 

Potassium Loss, Alkalosis, Hypokaliemia* 
In the past ten years there has become recog- 
nized a syndrome (usually in postoperative 
patients) consisting of distention, ileus, leth- 
argy, fever, weakness, dehydration and elec- 
trocardiographic evidences of altered neuro- 
muscular excitability. With this there is found 
a remarkable chemical situation consisting of 
metabolic alkalosis (a high carbon dioxide with 
normal or high sodium and often a low chlor- 
ide), hypokaliemia (a low plasma potassium 
concentration in the range of 2.5 to 3.5 mEq. 
per liter) and an acid urine, seemingly para- 
doxical. Some degree of azotemia may coexist if 
dehydration is severe. 

A considerable controversy has turned on this 
matter, particularly on the question of whether 
the potassium loss produces the alkalosis or 
the alkalosis lowers the potassium concentration 
and, indeed, on the central question of the 
role of potassium loss itself in the syndrome. 
There are several important facts which have 
emerged and which permit an understanding 
of the situation and, better still, effective pre- 
vention and treatment. 

Hypokaliemic alkalosis usually occurs in 
patients who have been alkalotic prior to sur- 
gery, or in those who have had an extrarenal 
loss pattern after surgery which could be ex- 
pected to produce alkalosis. Examples are 
patients with obstructed duodenal ulcer with 
preoperative alkalosis, or those having upper 
gastrointestinal surgery (pancreas, stomach) in 
whom postoperative gastrointestinal loss has 
been predominantly gastric juice. Alkalosis can 
be demonstrated to lower the plasma potassium 
concentration experimentally. In most surgical 
patients with this disorder, the alkalosis appears 
to be the important primary event. The preven- 
tion of alkalosis by the preoperative use of am- 
monium chloride and potassium chloride and 
by the conscientious replacement of extrarenal 
losses of chloride and of sodium (being ex- 
tremely careful to avoid overadministration of 



154 


Endocrinology and Metabolism in Surgical Care 


Chapter 6, 

sodium) is Lhe most important single step in 
the prevention of hypokaliemic alkalosis. 

J lypukaliemic alkalosis characteristically fol- 
lows a period of potassium deprivation when. 
urinary potassium loss is increased (the post- 
opcrati\^c state) and in the presence of extra- 
renal potassium loss (upper gastrointestinal dis- 
ease). But the full-blown syndrome can occur 
with the loss of only 100 niEcp of potassium if 
alkalosis is sudden and severe. The replace- 
ment of potassium is clearly of importance, and 
amounts as great as 120 niEcp per day may be 
given intravenously in treatment. But the effect 
of potasshmi advihiislration on serum poias- 
shm will he disappointing if the alkalosis re- 
mains uncorrected. Fortunately, potassium chlo- 
ride achieves both objectives simultaneously. 

Operative stress makes hypokaliemic alka- 
losis much more severe; the syndrome is most 
commonly seen in postoperative patients, the 
administration of ACTFi to alkalotic subjects 
produces a worsening of the alkalosis and hypo- 
kaliemia. It is thus clear that tissue stress plays 
some role here and it is our interpretation that 
stress acts by blocking the urinary sodium excre- 
don (aldosterone effect) which would other- 
wise help to compensate for the alkalosis. The 
important point again is to avoid surgery in 
alkalotic patients until their alkalosis is cor- 
rected. We regard any preoperative carbon 
dioxide concentration in plasma over 30 mM/1. 
as dangerous in this regard. 

Finally, the electrocardiograph is useful and 
provides a check on such patients at night or at 
times when a serum potassium concentration is 
hard to get, but the electrocardiographic 
changes are not due to changes in the serum 
potassium concentration alone and an electro- 
cardiogram cannot replace quantitative analysis. 

The recovery of patients with hypokaliemic 
alkalosis does not depend solely on restoration 
of the chemical values of the blood or the elec- 
trocardiogram to normal, but instead on solu- 
tion of the basic problem of gastrointestinal 
function. The patient’s life is threatened by 
hypokaliemic alkalosis and its prevention or 
treatment is of first-rank importance, but the 
restoration of normal gastrointestinal function 
must come also to produce recovery. The re- 
pair of the hypokaliemia will help promote re- 
sumption of normal neuromuscular function in 
the gut as well as the heart. 

Hypofoaicity; The Low Sodiiim Syndromes. 

With the increasing use of flame photometry 


for the study of plasma base* pauerns, there 
have been (jbscrved a large gmup ol surgical 
patients with low serum sodium concentrations, 
often as a feature ol sc\cre ilinc'ss. Since the 
sodium ion concentration is the most important 
single determinant in the scrum osmolarity 
(there being no resj)irat()i)' t'ompcnsal inn for 
its loss or gain ), a [xitient with a low scrum 
sodium usually has a h)'jv)tonic sertim and ex- 
tracellular fluid with an excess nl water both 
within and without cells. i\ot ini rctpiently ti 
high scrum potassium concentration is nlxscrvcd 
with the low sodium. Since it is one of the 
functions of the life process to pmvitk' cellular 
energy which maintains a higli potassium con- 
centration and low sodium con ccmi ration 
within the cell and the rmcmsc outside, it is 
evident that one of the nianifcslalions of cell 
illness and death will be the abolition ol this 
gradient, a fact histocheniicallv established by 
many observers. Because of this fact, a low 
serum sodium concentration is often associated 
with scx'cre illness and its passive repair by 
sodium infusion quite una\aiiiing; the repair 
of the primary pathologic process is followed 
by restoration to hcaltli and isoton id t>’ togt'thcr. 
Under other circumstances, an attempt to 
restore the sodium level may he lifesax'ing. It 
is, therefore, worthwhile to discriminate among 
the various hypotonic syndromes. 

1. Outright adrenal falhtre involves unregu- 
lated urinary sodium loss as has been men- 
tioned. Analysis of the urine for sodium is, 
therefore, the first step in diirercntial tliagnosLs 
of hyponatremia. If, in the {>resenee of a soruir 
sodium below 130 mEq./k, the urine sodium 
(in the absence of infusion) is ox'cr 30 to 50 
mEq./L, adrenal failure or renal failure (salt- 
losing nephritis) should be suspected, and suit- 
able differential study should be undertaken. 
As a first step in this study, the res{X)nsc of the 
renal sodium output to I)OC/V is useful in 
discriminating renal from adrenal failure. 

2. Large exirarenal losses of sodium can lead 
to a low serum sodium particularly if replaced 
inadvisedly by a large amount of sodium-free 
water, 

3. In the presence of uremia (with a high 
nonprotcin nitrogen) or diabetes (with a high 
sugar), or possibly other situations producing 
high crystalloid concentrations^ mild hype 
natremia can coexist with scrum isotonicity 
the abnormal crystalloid filling up the soluti 
total to normal. 



Common Abnormalities of Convalescence 155 


4. After tramna, it is a common phenomenon 
to find the sodium low and potassium high. 
The range here is not great. 

5. If none of the abo\’e four obtains (adrenal- 
renal failure, extrareiial loss, isotonic h\“po- 
natremia due to crystalloid excess, normal post- 
traumatic ^ shift"), one is probably dealing 
with hyponatremia as a manifestation of diffuse 
cellular ilhiess and the problem therapeutically 
is whether or not the use of concentrated salt 
solution is advisable. 

If the patient is edematous and suffering 
from disease of heart, liver or kidneys, the 
use of concentrated salt is very dangerous, and 
there is a wealth of evidence that such pa- 
tients have an excess of body sodium already, 
their basic defect is an inability to excrete water 
and an inability to exclude sodium from cells. 

If the patient is not edematous, a cautious 
trial of 300 cc. of a 3 per cent solution of 
sodium chloride daily for three days, with ob- 
servation of clinical and chemical effects, is 
justified, paying particular attention not only 
to the serum sodium response and urine out- 
put but also to the early signs of pulmonary 
edema and to the hypoproteinemia which may 
result. If the patient has been on a low-sodium 
diet and mercurial diuretics (the preoperative 
mitral stenosis patient, for example), the 
therapeutic trial is especially worthwhile, re- 
alizing that some degree of body deficit may 
be present, though rare. 

In any case, it is of singular importance to 
bear in mind that general nutritional care is 
often of greater effectiveness than an exclusive 
interest in the serum sodium concentration 
alone. Repair of anemia, avitaminosis and hy- 
poproteinemia and, above all, attention to 
caloric intake in the chronically ill, may be 
the most effective steps in restoring the serum 
sodium to normal and the patient to normal 
health. 

Prolonged Intravenons Feeding. If the 

patients sepsis or extrarenal losses are con- 
trolled but surgical convalescence still cannot 
proceed because of gastrointestinal difficulty 
requiring prolonged intravenous feeding, a spe- 
cial nutritional setting is introduced. An ex- 
ample is to be found in such a situation as 
foreshortening of the bowel, malfunctioning 
gastrointestinal anastomosis, esophageal ob- 
struction, or chronic peritoneal infection with 
ileus. 

Total intravenous feeding is never wholly 


successful in the sense of providing sufficient 
calories and nitrogen to achieve anabolism, re- 
sumption of weight and strength. It appears 
that introduction of food into the gastroin- 
testinal tract, as planned by Nature, is still 
necessary. It is important to emphasize that, 
in certain surgical conditions, introduction of 
food into the gastrointestinal tract may be done 
by means of gastrostomy or jejunostomy, mak- 
ing prolonged intravenous feeding unneces- 
sary. Occasional failure to recall the importance 
of this procedure, or inability to perform this 
operation with the accuracy and gentleness re- 
quired, has produced tragic results. 

When such an operation is inadvisable be- 
cause of more distal disease in the gastro- 
intestinal tract, prolonged intravenous feed- 
ing ma\' be undertaken with the following 
general rules in mind: 

Water, sodium, chloride and potassium 
should be provided daily. 

The administration of w^ater and salt each 
day should be carefully gauged by measured 
observation of the patient’s weight and of ex- 
trarenal losses. The patient should not gain 
or lose weight rapidly. He should be expected 
to lose about 150 to 200 gm. a day as his fat 
stores are burned. 

One whole blood transfusion should be 
given approximately each week to provide 
trace minerals, electrolytes and erythrocytes 
not found in pharmacologic solutions. 

/Adequate intake of vitamins is vital. 

If the patient is unstressed, he will anabolize 
from intravenous protein hydrolysate if ade- 
quate calories are also supplied. The provision 
of amino acids in the form of protein hydroly- 
sates finds its maximal usefulness here. 

The provision of adequate calories is a chal- 
lenge. Concentrated glucose solution given 
into a caval catheter and the use of alcohol 
and fat emulsion may all be useful. 

But, above all, the patient should move over 
to enteral ingestion of food as soon as possible. 
During the transition phase one should remem- 
ber that parenteral provision of glucose *Tills 
appetite/' In a chronically ill patient whose 
stomach is not accustomed to accepting food 
and who has lost the habit of appetite, it is es- 
sential to omit the provision of intravenous 
calories for a few days so as to stimulate ap- 
petite as the enteric channel is reopened. 

Preoperafive Bodily DepIetioH. The sur- 
geon frequently must operate upon patients 



156 


Chapter 6. Endocrinology and Metabolism in Surgical Care 

depleted by chronic disease. Commonest of the meaning of the high biologic priority 

amongst the chronic diseases are chronic sepsis, of the wound in the early phase of eon- 

gastrointestinal cancer and chronic congestive valescence. 

heart failure. Though these three entities are If blood loss has been a part ol tlie depicting 
seemingly of far different etiology, their effects disease process (as in carcinoma o( the right 

on body composition are similar. There is colon, for example), the blood volume will be 

a loss of weight due to loss of both fat and low, particularly in the red cell Iraction. If 

lean tissue. After a few months of illness, blood loss has not been prominent (carcinoma 
most of the available body fat has been mobil- of the esophagus, mitral stenosis), these wasted 
ized and oxidized. There is, therefore, a rela- patients commonly have a normal or high 
tive increase in body water (largely extra- blood volume with a definitely elevated {liasma 

cellular) because of the loss of fat which oc- volume and a slightly low hematocrit reading, 
cupies the nonaqueous phase of body composi- Massive transfusion of these patients preopera- 
tion. In addition, the chronically depleted pa- lively is based on the impression, olten er- 
tient shows a marked tendency to retain salt roneous, that they have a chronic blood v'oliime 
and water. This is responsible for starvation deficit This impression is based on the slightly 
edema. If there is disease of heart or liver, low hematocrit reading. The transfusion will 
this water and salt retention is greatly ac- load down the circulation with excess fluid, 
centuated, as has been known for centuries, only to embarrass anesthetic and postoperative 
The chronically depleted patient approaching management. If these patients’ depleting 
surgery is, therefore, a patient who has too process has been accompanied by true hemor* 
little fat, too little lean tissue, too much body rhage, their red cell mass may be \Try low and 
water, too much of which is extracellular the judicious use of whole blood transl’usions 
water and too much extracellular salt (sodium or of packed cells may be quite valuable. Be* 
and chloride) in his body. His response to ware o£ sudden increases in blood volume in de- 

trauma is quite characteristic. The depression pleted, elderly patients! Again, “nudge,” don’t 

of eosinophils and rise in blood and urine ‘"swamp,” the depleted incli\dclLial. 
steroids are quite active but they are very Depleted patients have lost their “metabolic 
transient. The quantitative steroid changes are reserve” and are extremely sensiti\’c to several 
not great and they rapidly revert to normal, metabolic challenges. First amongst these is 
The loss of nitrogen in the urine is not great infection. Such patients have little ability to 
and the patient will return to positive balance withstand the catabolic ravages of sepsis and 
with low calorie-nitrogen ratios. If he is man- if they are overtaken by invasive sepsis they 
aged "gently” and water and salt overloading will frequently very rapidly succumb. Sec- 
avoided, the chronically depleted patient will ondly is massive injury. Such patients can 

pass through his surgical experience quite un- withstand gentle management and surgery 

eventfully, and wound healing will usually he which is not too extensive; their wounds heal 
quite normal. nicely. If the tissue insult is too great, such 

Although such careful management will usu- patients do not rally well, will develop renal, 
ally produce a well-healed wound and a sue- hepatic or pulmonary failure and failure of 
cessful convalescence, the over-all incidence wound union, and will succumb. Thirdly, 
of wound dehiscence or primary failure of these patients are very vulnerable to overad- 
fibroblastic union is slightly higher in this ministration of water and salt; serious positive 
group than in the previously well-nourished balances are quickly established, with resultant 
subject. This is especially true of patients hemodilution, hypoproteinemia and pulmonary 
with cancer, particularly if the disease has edema. Cough reflexes arc poor, effort small 

reached the inoperable stage. Nonetheless, and aspiration common. The cause of death 

the incidence of dehiscence in the group as a observed at postmortem examination usually 
whole is low in absolute terms-about 2 per includes ""bronchopneumonia” or interstitial 
cent. The remarkable thing is that given good pneumonitis; there may also be pulmonary 
technique in closing such a wound, adequate edema and a mixed renaf lesion. In some in- 

vitamins, avoidance of salt overloading, the stances, the pathologist can cast little light on'' 

great majority of these wounds do heal well the mechanism of death. It is for these reasons 
despite advanced tissue wasting—an example that staging of procedures and dextrous gentle 



157 


Common Abnormalities of Convalescence 


surgery with careful metabolic management 
are of such importance in chronically depleted 
individuals. 

It should be emphasized that patients who 
have lost one-eighth to one-tenth of body 
weight largely as fat and who still have 
strength to walk vigorously around the ward 
with good vital capacity and normal extra- 
cellular chemical balance, are excellent risks 
for extensive surgery. They are in many ways 
a better risk for surgery than is the overfed, 
obese man and woman with a tremendous 
omentum full of fap decreased diaphragmatic 
excursion and flabby muscles. It is rightly em- 
phasized by the nutritionists that the great 
hazard of the American population is not mal- 
nutrition but overnutrition, and this is very 
true in surgery. 

Infection. Acute sepsis without trauma 
has in itself many of the metabolic and endo- 
crine aspects of acute trauma. There is a 
speeding up of the metabolic wheel, resulting 
in rapid loss of weight due to oxidation of fat 
and loss of nitrogen. There is an adrenal 
secretory increase and an eosinopenia. There 
is also a clear-cut tendency to retain water 
and sodium. If sepsis complicates surgery and 
is rapid in onset after surgery, there is a 
marked intensification of the clinical and meta- 
bolic effects of trauma. The patient looks much 
sicker, his fever is higher, the nitrogen loss is 
increased and body wasting is even more rapid. 

* If the infection is quickly brought under 
control, as by drainage of an abscess, ex- 
teriorization of damaged bowel, or effecth^e 
administration of antibiotics, the patient will 
then pass into a recovery phase quite normally. 

When the sepsis is somewhat more long-con- 
tinued as in unresolved peritonitis, infected 
open wounds, or osteomyelitis after fracture, 
the continuation of sepsis amounts to an in- 
definite prolongation of the catabolic phase of 
metabolism. With continued sepsis and puru- 
lent discharge, even though the temperature 
be normal, the pulse is elevated and measure- 
ments of metabolism show that the eosinophils 
are down, the serum steroids remain elevated, 
wound losses may be considerable and the 
urinary nitrogen loss persists. The presence 
of sepsis thus prolongs the catabolic phase 
after trauma and, more importantly, post- 
pones for as long as sepsis is active the corti- 
coid-withdrawal phase and resumption of nor- 
mal anabolism. 


This fact has several extremely important 
corollaries in clinical management. The obliga- 
tOTV catabolism of sepsis in its acute febrile 
phases seems to be a counterpart of the obliga- 
tory catabolism following injury in that it is 
difficult to affect either the clinical course of 
the disease or the rate of nitrogen loss in the 
urine bv' the pro\ision of large intakes. But 
as the acute infection is initially controlled, 
the patient quickly passes into a period in 
which intake is of critical importance. If 
chronic infection is present, the provision of 
this intake may be difficult and threatening 
nutritional deficits develop rapid!}'. A ready 
example is found in the late burn with infected 
open wounds. After only a week or two of 
thoughtless neglect, such a patient will show 
anemia, avitaminosis, hypoproteinemia, and 
edema. Under such circumstances, the admin- 
istration of large intakes may be extremely 
beneficial in reducing the rate of body wasting, 
even though anabolism has not yet been pro- 
duced. Patients with chronic septic processes 
furnish the chief examples in general surgery 
of the usefulness of forced feeding, using an 
indwelling gastric tube when needed. 

Fractures and Extensive Wounds. Certain 
endocrine and metabolic features of fractures, 
extensive wounds and burns are worthy of 
mention because each has endocrine and meta- 
bolic characteristics which set it apart from 
the stress of primary elective anesthetized soft 
tissue trauma. All three are examples of the 
importance of the wound in determining the 
depth, duration and details of early catabolism 
despite the similarity of their initial endo- 
crinology. 

Midshaft fractures in young individuals pro- 
duce a very intense nitrogen catabolism which 
far outlasts the early period of endocrine activ- 
ity or the period of starvation. Changes in 
eosinophils and blood and urine steroids may 
be no more prolonged than after soft tissue 
trauma. The prolonged loss of nitrogen, cal- 
cium and phosphorus is quite remarkable. The 
loss of calcium and phosphorus is traceable in 
part to the skeletal immobilization which is in- 
trinsic in treatment, and in part to release 
of these electrolytes from the fracture site 
itself. The more prolonged nature of the 
wound-healing process required to restore the 
injured part to tensile integrity is apparently 
associated with a much more prolonged phase 
of nitrogen loss. It is for this reason that body 



158 


Chapter 6. Endocrinology and Metabolism in Surgical Cure 


wasting is more noticeable and that a much 
longer late phase oF rel'eccling is essential. 
There is also good evidence that iF intakes 
can be maintained at a maximal lend alter 
the first week or so, the net loss I'rom the body 
is reduced e\uii though the absolute nitrogen 
excretion rate is increased. 

Fractures which produce little systemic re- 
sponse are most clearly seen in the intracap- 
SLilar subcapital femoral neck fracture. Here, 
a Fracture which (jccupies as much bone cross- 
section as a midshaft Fracture is associated with 
very little muscle disorganization or hematoma 
because of its intracapsuiar position. The rcTa- 
ti\'ely minor blood supply of the region is note- 
worthy. It is possibly a significant correlation 
that the intracapsuiar subcapital femoral neck 
fracture, with its minimal metabolic response, 
is less apt to heal to good union. 

The extensive wound of war may take any 
anatomic form. Very typical of a large number 
of the seriously wounded is a w^ound due to 
multiple penetrating fragments of artillery, 
mortar or mine missiles, and involving in- 
juries to the skeleton, the body cavities, and 
hollow viscera. The result is massive blood 
loss, contamination of injured tissues, and a 
large cross-sectional trauma. 

From the evidences available, the endocrine 
response appears also to be massive. The 
amount of adrenal medullary activity observed 
in shocked soldiers is great and this would lead 
us to believe that the cortical steroid output 
also is imposing although fewer data are avail- 
able. Eosinophil counts are low for many days 
and when they gradually resume a higher 
value they may then be observed to be at 
extremely high levels (3000 to 4000 cells per 
cu. mm.) for many days or weeks. The amount 
of surgery involved is great as fractures must 
be set, bleeding stopped, devitalized tissue 
debrided and hollow viscera either repaired 
ox exteriorized. The actual extent of the 
trauma, viewed as a physiologic insult to the 
patient, is the poduct of the initial cross-sec- 
tional trauma involved, the total blood lost, 
the duration of time which ensues between 
the initial injury and the completion of 
definitwe surgery, and the details of the 
definitive surgery itself. The latter includes 
debridement and immobilization. 

The . metabolic response which ensues is, 
therefore, doubly large, not only because the 
trauma is large but because it characteristically 
occurs in the athletic, healthy and well-nour- 


ished young adult male, lleniarkable degrees 
of body wasting are observed. T he jxitient 
may lose 25 j)er cent of his hodv weight in 
the hrsl month. IF sepsis can he controlled and 
visceral Function (particularly renal Function) 
maintained, the patient will coinalesce if he 
finally has access to adecjuate oral nutrition; 
only through this medium can convalescence 
be assured. 

Special problems of shock, the blood vol- 
ume and renal failure present theinseh’cs regu- 
larly amongst the sevcrelv' wounded. The three 
are interrelated for the clear reason tliai an 
accurate knowledge ol blood \a)lLinie physi- 
ology is essential to the treatment of shock, 
renal lailure usually Follows shock, and the 
post-trauma metabolism is a \’ieioiis cause of 
hyperkaliemia in this setting. 

Continued oligemia is the eoininonest cause 
of continued shock. The term "irre\'ersible 
shock” should not be used in the ease of these 
patients. More olten than not it merely hides 
ignorance of other factors such as pneumo- 
thorax, liemopericardium, or continued uncon- 
trolled hemorrhage, all of which are susceptible 
to treatment whereas the concept ol irrev'crsible 
shock only connotes hopelcssne.ss. 

Once shock has developed, the amount of 
transfusion needed to restore the circulation is 
greater than the established deficit, he it esti- 
mated by history or measured directly. 

If oliguria persists, the stei>s outlined should 
be followed with care to avoid overloading the 
patient with intravenous thenipy. 

Burns. The metabolic variants of a burn 
are most clearly seen in two respects. First, the 
water and salt picture is different from that 
associated with any other form of trauma. A 
major burn produces a large accumulation of 
edema under the area of thermal trauma, owing 
to thermal damage to capillaries. This segre- 
gates a large volume of water and salt which 
is derived from the plasma volume, reducing 
the blood volume with a resulting high hemato- 
crit reading. Oligemic shock supervenes unlcs.s 
adequate plasma volume support is carried out 
with some sort of colloid-containing fluid, of 
which plasma or one of the plasma expanders 
is by far the most commonly used. When 
given into the plasma to maintain plasma vol- 
ume, these in turn leak out in part into the 
burn. The result is a large accumulation of 
water and salt which produces an early weight 
gain and strongly positive water and salt bal- 
ances. Positive sodium balances in patients 



159 


Common Abnormalities of Convalescence 


with major burns, early and adequately treated, 
may run between 500 and 1500 mEq. in the 
first forty-eight hours, depending on details of 
therapy. The weight gain which results is 
accordingly unique. It a^'erages, in our experi- 
ence, very close to 10 per cent of the initial bod\’ 
weight of the patient and this correlates with 
the fact that the extracellular fluid space is ex- 
panded to approximately twice normal. After 
two to five days, this fluid is diuresed, weight 
rapidly falls and a convalescent pattern de- 
manding caloric intake and more reminiscent 
of other forms of trauma is resumed. If renal 
insufficiency occurs and the patient cannot 
have a diuresis, convalescence is interrupted 
and recovery is rare. 

Second, the nitrogen-calorie relation resem- 
bles fractures in that there is a very prolonged 
period of nitrogen loss, loosely correlated with 
the duration of the unhealed wound. It long 
outlasts the period of steroidal activity. It lasts 
the length of time that the wound would ordi- 
narily be expected to take to heal. If the open 
wound persists long after this time as small 
unhealed areas, it will be extremely difficult 
to heal. Here, as in the fracture, the pro- 
vision of nutrition as soon as gastr*ointestinal 
acceptance occurs minimizes the body wasting. 

Endocrine Disease. Shortly after the de- 
scription of the importance of the adrenal 
steroids in postoperative endocrinology, the 
concept became widespread that adrenal failure 
would turn out to be a common cause of dif- 
ficulties in surgical convalescence. Such has 
not been borne out by subsequent experience. 
Outright adrenal failure in patients previously 
unsuspected of endocrine disease is quite rare, 
but its importance cannot be overestimated 
for the individual patient in wffiom it occurs 
and there are lesser degrees of abnormality 
which are more common. 

Adrenal failure after operation is manifested 
by high fever, tachycardia, hypotension, oli- 
guria, shock and coma. The administration of 
large amounts of blood, plasma, antibiotics and 
water-and-salt are all of some slight assistance 
but remarkably nonspecific. If the patient has 
some degree of visceral congestion initially, 
this massive administration of parenteral fluids 
. will ultimately be fatal. By contrast, the re- 
sponse to intravenous hydrocortisone is so 
dramatic as to constitute one of the spectacular 
experiences of a surgical career. 


The diagnosis of adrenal failure must, there- 
fore, be considered in any patient who is not 
doing well after surgery. The eosinophil count 
should be made and, whenever possible, meas- 
urements of the blood and urine steroids 
should be carried out. If, within three days of 
surger\, and with an cxtremelx ill patient, the 
eosinophil count is o\'er 50 per cu. mm., a very 
high degree of suspicion should be aroused. 

\^ffiethcr or not the eosinophil count is ele- 
vated, and if there is reasonable suspicion that 
other forms of hypotension and oliguria hat'e 
been adequately considered and treated, a 
specific therapeutic trial with hydrocortisone 
given intravenously is indicated. It is always 
unfortunate wdien “blind" therapy is given 
for any condition in medicine or surgery. There 
are certain circumstances, however, in which 
the hazard is so small, and the possible benefit 
so great if the diagnosis turns out to be cor- 
rect, that blind therapy is justified. In the 
postoperative patient who has been accurately 
transfused, whose water balance has been 
carefully considered and adequately handled, 
whose airway and pulmonary and cardiac func- 
tion show no important defects, and who is 
bordering on shock or is in shock, the adminis- 
tration of hydrocortisone intravenously in a 
dose of 100 mg. in 500 cc. of a 5 per cent solu- 
tion of dextrose in water is a justified pro- 
cedure. A positive response is of tremendous 
significance. 

In the acute emergency, the employment 
of cortisone or hydrocortisone is more rational 
than ACTH since the latter is unavailing if 
there is significant adrenal disease. 

When the administration of hormone to sur- 
gical patients is used as a disguise for inade- 
quate diagnosis, it is to be deplored; when in- 
telligently applied it is, of course, useful. The 
cause of postoperative adrenal failure is most 
commonly subclinical Addison’s disease or 
acute adrenal hemorrhage, the latter often as- 
sociated with the use of anticoagulants. 

When the adrenals are removed surgically, 
as in the treatment of carcinoma, one deals 
with postoperative hypoadrenalcorticism which 
is treated by specific administration of adreno- 
cortical hormones, the therapeutic pattern of 
which should mimic the normal metabolic and 
endocrine response to surgery. 

Myxedema and diseases of the pituitary 
also are accompanied by postoperative 'meta- 



160 


Chapter 6. Endocrinology and M embolism in Surgical Care 


bolic decompensation.” If these are present, 
administration of appropriate hormones, either 
thyroid, ACTH or cortisone, should be carried 
out 

Chronically ill patients, such as the ])atient 
with the late burn (or the patient in the later 
phases of peritonitis with localized abscess 
formation), will frequent!}' carry a resting 
high eosinophil count and when operated upon 
the eosinophil count will rise to extremely high 
levels, such as 2000 to 3000 per cu. mm. This 
does not indicate adrenal failure. Adrenal 
failure is manifested not only by a high eosino- 
phil count, which is an isolated laboratory ob- 
servation also producible by a variety of other 
mechanisms (including allergy), but by actual 
metabolic changes, the most striking of which 
are failure to maintain blood pressure, unregu- 
lated loss of salt in the urine, and fever. 

Once the administration of hydrocortisone 
is started, it should be maintained for a lim- 
ited time not to exceed five days. The patient 
should be kept on antibiotics and given suit- 
able gastric antacid therapy to avoid the com- 
monest complications which are sepsis and 
bleeding peptic ulcer. At the end of that time, 
the hormone should be '^tapered” off and the 
patients own adrenal response tested by the 
response to ACTH and by appropriate urine 
steroid measurements. Precise localization and 
assessment of the defect is then possible. Pro- 
longed administration of ACTH or cortisone 
results in relative adrenal insufficiency when 
the drug is stopped; this must be taken into 
consideration in all patients operated upon 
after prolonged administration of these hor- 
mones. 

Renal Failure. The subject of metabolism 
in surgical patients with acute or chronic 
renal disease is one of considerable importance 
in present-day surgery. Lower nephron nephro- 
sis, otherwise referred to as ischemic nephrosis, 
post-traumatic renal insufficiency, pigment 
nephrosis, the crush syndrome or tubular de- 
generation, is most commonly observed in pa- 
tients after wounds or operations. All these 
terms are to some extent synonymous and 
when applied to the severely injured patient 
or the patient who has been in shock after 
surgery, they indicate minor clinical varia- 
tions in a renal picture most simply referred 
to as acute renal failure. Over two-thirds of 
the incidences of occurrence of this syndrome 
arise from either surgical or obstetrical epi- 
sodes. The commonest causes are massive in- 


jury with hemoglobin Liriii, nnoglobinuria and 
shock, surgical shock itself, misniatchccl trans- 
fusions and obstetrical eoinplications iinolv- 
ing hemorrhage such as premature separation 
of the placenta. 

The treatment of such patients centers on 
early diagnosis. The diagnosis tluil the patient 
is passing into a phase ol renal disease, rather 
than oliguria due to hypotension and dehydra- 
tion, rests upon the Uncling of a small and fall- 
ing urine output at fixed speeilie gra\ it\' despite 
the restoration of norma! blood pressure and 
hydration, with a rising blood urea and serum 
potassium value. 

Once this diagnosis is suspected the patient 
should be treated by “balance,” avoiding any 
sudden weight gains or losses which indicate 
sudden shifts in body waiter \a)lLiine. harly 
recognition of the problem and adhcTcnce to 
this principle during the first fort\ eight hours 
may he lifesaving. Those in charge of the 
patient all too [rct|uently sulTer under the de- 
lusion that large water or salt infusions will 
“open” or “flush out” the kidneys, if hydration, 
blood volume and blood pressure are normal 
the kidneys will reesuine function when they 
can; large infusions (over 1000 ee. })c‘r day) 
only threaten life by overburdening the cir- 
culation. 

Conservative therapy, avoiding overloading 
the patient with water and salt, maintaining 
water balance, maintaining normal blood vol- 
ume and avoiding the prolongation of sepsis 
will be followed by spontaneous diuresis and 
recovery in a substantial fraction of the pa- 
tients. 

Increase in the blood level of urea and re- 
lated compounds does not seem to do the pa- 
tient a great deal of harm. The accumulation 
of potassium in the extracellular phase is the 
chief threat to life in this disease. The ac- 
cumulation of metabolic acids producing acido- 
sis is also extremely hazardous. The rate of 
accumulation of both is greatly accelerated 
after injury and they act syncrgistically. When 
these occur and the patient continues to be 
oliguric, treatment by ordinary measures is 
often unavailing. The patient should be re- 
ferred or transferred to a center where renal 
insufficiency is frequently dealt with and 
where methods of artificially dialyzing these 
substances out of the blood are available. 
Early transfer is safe or feasible; procrastina- 
tion based on false hope is fatal 

Siwnmary. No single summarizing .state- 



161 


Common Abnormalities of Convalescence 


ment is possible. Normal endocrine and 
metabolic processes underlie surgical con- 
valescence. Their understanding as normal 
phenomena is the key to a rational and effec- 
tive treatment of the metabolic abnormalities 
which are so common in all fields of surgery. 

READING REFERENCES 

Bland, J. H.: The Clinical Use of Fluid and Electro- 
lyte. Philadelphia, W. B. Saunders Company, 1952. 
Bliss, E. L., Sandberg, A. A., Nelson, D. H., and 
Eik Nes, K.: The Normal Levels of 17-Hydroxy- 
corticosteroids in the Peripheral Blood of Man. 
J. Clin. Investigation J2;818, 1953. 

Blount, H. C., Jr., and Hardy, J. D.: Thyroid Func- 
tion and Surgical Trauma, as Evaluated by Iodine 
Conversion Ratio. Am. J. M. Sc. 224:112, 1952. 
Bonner, C. D.: Eosinophile Levels as an Index of 
Adrenal Responsiveness. Factors That Affect V^aluc 
of Eosinophile Counts. J.A.M.A. 148:634, 1952. 
Browne, J. S. L., Schenker, V., and Stevenson, J. A. F.: 
Some Metabolic Aspects of Damage and Convales- 
cence. (Abstract). J. Clin. Investigation 23:932, 
1944. 

Cannon, Walter B.: Bodily Changes in Pain, Hunger, 
Fear and Rage. New York, D. Appleton & Company, 
1915. 

Coller, F. A., Campbell, K. N., Vaughan, W. H., and 
lob, L- V.: Postoperative Salt Intolerance. Ann. 
Surg. 119:533, 1944. 

Cope, 0., Nardi, G. L., Quijano, M., Rovit, R. L., 
Stanbury, J. B., and Wight A.: IMetabolic Rate and 
Thyroid Function Following Acute Thermal Trauma 
in Man. Ann. Surg. 137:165, 1953. 

Cuthbertson, D. P.: Observations on the Disturbance 
of Metabolism Produced bv Injury to the Limbs. 
Quart. J. Med., N.S. 1:233,' 1932. ' 

Davenport, Horace W.: The ABC of Acid-Base Chem- 
istry. Chicago, The University of Chicago Press, 
1950. 

Dudley, H. A., Boling, E. A., LeQuesne, L. P., and 
Moore, F. D.: Studies on Antidiuresis in Surger>n 
Effects of Anesthesia, Surgery and Posterior Pitui- 
tary Antidiuretic Hormone on Water Metabolism in 
Man. Ann. Surg. 140:354, 1954. 

Franksson, C., Gemzell, C. A,, and von Euler, U. S.: 
Cortical and Medullar}^ Adrenal Activity in Surgical 
and Allied Conditions. J. Clin. Endocrinol & Metab. 
14:608, 1954. 

Hardy, James D. : Surger>^ and the Endocrine System. 

Philadelphia, W. B. Saunders Company, 1952. 
Howard, J. E.: Protein Metabolism during Con- 
valescence after Trauma. Recent Studies. Arch. 
Surg. 50:166, 1945. 

Howard, J. M., Olney, J. M., Frawley, J. P., Peterson, 
R. E., Smith, L. H., Davis, J. H., Guerra, S., and 
Dibrell, W. H.: Studies of Adrenal Function in 
Combat and Wounded Soldiers. Ann. Surg. 141: 
304, 1955. 

Hume, D. M.: The Role of the Hypothalamus in the 
Pituitary Adrenal Cortical Response to Stress. J, 
Clin. Investigation 28:790, 1949. 

Flume, D. M., and Nelson, D. H.: Corticoid Output 
in Adrenal Venous Blood of the Intact Dog. Federa- 
tion Proc. 13:73, 1954. 


Ingle, D. J., W^ard, E. 0., and Kuizenga, M. H.: The 
Relationship of the Adrenal Glands to Changes in 
Urinat}' Non-protein Nitrogen following Multiple 
Fractures in the Force-fed Rat. Am. J. Physiol. 149: 
510, 1947. 

LeQuesne, L. P.; Fluid Balance in Surgical Practice. 
London, Lloyd-Luke, 1954, 128 pp. 

Lockwood, J. S., and Randall, H. T.: The Place of 
Electrolyte Studies in Surgical Patients. Bull. New 
York Acad. Aled. 25:228, 1949. 

jMerrill, J. P., Levine, H. D., Somemlle, W., and 
Smith, S. III.: Clinical Recognition and Treatment 
of Acute Potassium Intoxication. Ann. Int. Med. 
33:797, 1950. 

Moore, Francis D.: The Adaptation of Supportive 
Treatment to the Needs of the Surgical Patient. 
J.A.M.A. 141:646, 1949. 

Moore, Francis D.: Burns. An Annotated Outline for 
Practical Treatment. Symposium on Specific Meth- 
ods of Treatment. M, Clin. North America 36: 
1201, 1952. 

Moore, Francis D.: Bodily Changes in Surgical Con- 
valescence. 1. The Normal Sequence — Observations 
and Interpretations. Ann. Surg. 137:289, 1953. 

Moore, F. D.: Low Sodium Syndromes of Surgery. 
Outline for Practical Management. J.A.M.A. 154: 
379, 1954. 

Moore, F. D.: The Significance of Weight Changes 
after Trauma. Editorial. Ann. Surgery 141:141, 
1955. 

Moore, F. D.: The Endocrine Response to Trauma. 
Proc. Roy. Soc. Med. In press. 

Moore, Francis D., and Ball, Margaret R.: The Me- 
tabolic Response to Surgery. Springfield, 111., Charles 
C Thomas, Publisher, 1952. 

Moore, F. D., Steenburg, R. W., Ball, M. R., Wilson, 
G. M., and Myrden, J. A.: Studies in Surgical En- 
docrinology. L The Urinary Excretion of 17-Hy- 
drox}'corticoids and Associated Metabolic Changes, 
in Cases of Soft Tissue Trauma of Varying Severity 
and in Bone Trauma. Ann. Surg. 141:145, 1955. 

Nichols, J. A., Wilson, P. D., and Umberger, C. J.: 
Observations on Adrenocortical Function in Patients 
Undergoing Operations upon the Bones and Joints. 
Surg., Gynec. & Obst. 99:1, 1954. 

Roberts, Kathleen E., Randall, Henry T., Philhin, 
Philip, and Lipton, Rita: Changes in Extracellular 
Water and Electrolytes and the Renal Compensa- 
tion in Chronic Alkalosis, as Compared to Those 
Occurring in Acute Alkalosis. Surgery 36:599, 
1954. 

Selye, H.: “Conditioning” Various ‘'Permissive” Ac- 
tions of Hormones. J. Clin. Endocrinol. & Metab. 
14:122, 1954. 

Simpson, S. A., Tait, J. F., Wettstein, A., Neher, R., 
Euw, J. V., Schindler, O., and Reichstein, T.: Kon- 
stitution des Aldosterons, des neuen Mineralocor- 
ticoids. Experientia 10:132, 1954. 

Steenburg, R. W.: A Study of the Free 17-Hydroxy- 
corticosteroids on the Peripheral Blood of Surgical 
Patients. Surgical Forum, American College of Sur- 
geons, 1954. Philadelphia, W. B. Saunders Com- 
pany, 1955, p. 593. 

Steenburg, R. W., Ganong, W. F., and Moore, F. D.: 
The Effect of Extra-adrenal Factors on the Free 
Serum 17-Hydroxycorticoids in Surgically Stressed 
Experimental Animals. Surgery 38:92, 1955. 



Endocrinology and Metabolism in Surgical Care 


1 62 Chapter 6. 

Steenburg, R. W., Lennihan» R.., and Moore, F. D.: 
Studies in Surgical Endocrinology. 11. The Free 
Blood 17-H3"droxycorticoids in Surgical Patients; 
Their Relation to Urine Steroids, Metabolism and 
Convalescence. Ann. Surg. In press. 

Thorn, G. W., Jenkins, D., and Laicllaw, J. C.: The 
Adrenal Response to Stress in Man. In: Recent 
Progress in Hormone Research. Proc. of the Laii- 
rentian Hormone Conference. G. Pincus, Editor. 
Neu^ York, Academic Press, Inc., 1953, Vol. 8, p. 
171. 

Tyler, F. FI., Schmidt, C. D., Eik Nes, K., Brown, FI., 
and Samuels, L. T.: The Role of the Liver and the 


Adrenal in Producing Elevated Plasma 17-FIydroxy- 
corticosteroid Levels in Surgery. J. Clin, investiga- 
tion 33:1507, 1954. 

Wangensteen, O. 1:1. , and Zimincrman, B.: Observa- 
tions on Water Intoxication in Surgical Patients. 
Surgery 31:654, 1952. 

Wilkinson, A. W., Billing, B. Id., Nag\', G., and 
Stewart, C. P.: Excretion of Chloride and Sodium 
after Surgical Operations. Lancet I.-64(), 1949. 

Wilson, G. M., Edelman, L S., Brooks, I ,., M>'rden, 

J. A., Flarken, D. E., and Moore, F. D.: Metabolic 
Changes Associated with Mitral Valvuloplasty . Cir- 
culation 9:199, 1954. 



7 


Anesthesiology 

By JOHN ADRIANI, M.D. 

John Adriani went front his home in Bridgeport, Connecticut, to Columbia Uni- 
versity for his college and medical school degrees. A surgical internship and a 
fellowship in physiology paired the way for his training in anesthesiology. His 
interest has a broad base and recognizes the mutual co-operation necessary between 
surgeon and anesthesiologist for the best care of the patient. He has spent his pro- 
fessional life thus far in New Orleans where he guides anesthesiology in the medical 
schools ofTulane and Louisiana State University. 


Anesthesia is an adjunct to patient care. Sur- 
gery, as it is now practiced, would hardly be 
possible without it. Although physical agents, 
such as pressure, cold and electric currents, may 
be used to induce anesthesia the practical 
methods for its production entail the use of 
chemical substances which depress the activity « 
of nervous tissue. These chemical agents 
either act systemically and depress the central- 
nuclei, or they act locally and block the activity 
of a nerve fiber when applied directly to its 
surface. Thus, anesthesia is recognized as gen- 
eral or systemic, and local. More precisely, local 
anesthesia is referred to as regional or conduc- 
tion anesthesia. Regional anesthesia is sub- 
divided into types named according to the site 
of application of the drug used to produce it, 
namely, spinal, epidural, paravertebral, nerve 
block, field block, infiltration and topical 
To be surgically useful, an anesthetic drug or 
method of producing anesthesia must fulfill, 
two purposes: (1) it must abol M refiex. acti\iit \>’ 
and other responsesToTumuliand (2) it must 
pro vide muscle re l axation. A third requirement, 
loss , o£.x:QiisciQusnes$, is desirable but is not 
alw'ays necessar^T^^ 

GENERAL ANESTHETICS 

The general anesthetics are volatile sub- 
stances which are administered by inhalation, 
or nonvolatile drugs which are administered by 

Page 


routes other than inhalation. The vi^atile drugs 
differ in pharmacologic characteristics from the 
nonvolatile. The members in each group are 
similar ph'armacologically and arc used for the 
same purposes. ii 

The \^olatiIe drugs are cQmpl £te-.anesthe^ 
They cause a blockade along the path from the 
periphery^ to the pain perception centers. T%^- 
l oss of s ensibility is accompanied by a loss o f 
cons ciousnes s. Loss pL muscle to Pe of varying 
degrees is obtained, depending upoif the potency 
of the drug. Volatile anesthetics are inert; that 
is, they a re not altered hv th e cells. They are 
eliminated unchanged by exhalation. They are 
gases, or highly volatile liquids, wdiich boil 
below^ 60"' C. With the exception of nitroirs.- 
oxide, currently used drugs are hydrocarbons, 
ethers or lialogenated hvdi'ocarbons. Three 
gases, nitroi>&-^xid^xth\^ene and cyclopi^ancy 
and fivejiquids, ether, vinyl ether, chloroform, 
ethyl chloride and trichlorethylcne, are used. 

The nonvolatile drugs, on the other hand, 
are incomplete anesthetics. None completely 
blocks the passage of impulses from the periph- 
ery to the t halamic nuclei . A hypnotic state, 
from which me patient may be roused, is ob- 
tained with therapeutic doses. Larger doses pro- 
duce a more profound state of depression ac- 
companied by amnesia and partial obtunding of 
reflex activityn^o^ which abolish reflex 
activity and produce anesthesia in a surgical 

163 



164 


Chapter 7 . Anesthesiology 



Figure 1. InsufHation technique. The volatile liquid is vaporized by bubbling air, oxygen or a mixture of an 
anesthetic gas and oxygen (A) through the container (B) and the mixture is eoiulucted into the upper 
respiratory passages. In oral and pharyngeal surgery a cannula (D) conducts the anesthetic mixture into the 
mouth. A catheter may be used for nasopharyngeal or direct insulllation into an intratracheal catheter or 
cannula. (From Adrian!: Techniques and Procedures of Anesthesia. Courtesy Charles C Thomas, Publisher.) 



sense de press the medullary centers un duly and 
give rise to”^Ifailator3ran depres- 

sion. The nonvolatile drugs, unlike the volatile, 
cannot be used as sole agents for surgical anes- 
thesia. In present-day practice it is common to 
combine nonvolatile with volatile drugs. The 


former provide sedation or basal narcosis; the 
latter, analgesia and suppression of reflex activ- 
ity. One complements the other. The non- 
volatile drugs are liquids whose boiling points 
are too high to permit adequate vaporization 
for inhalation, or they are solids. Chemically, 




General Anesthetics 


165 


the majority are aliphatic compounds, deriva- 
tives of urea or alkaloids. The aliphatic com- 
pounds are alcohols, halogenated alcohols or 
halogenated aldehydes. Numerous deri\'atives 
of urea are available, the most useful of which 
are the barbiturates. The are narrotir 

substances; that is, they possess both analgesic v- 
and hypnotic properties. The analgesic power, 
how^ever, is not sufficient to abolish reflexes and 
relieve sharp pain. Narcotics thus possess little 
usefulness as surgical anesthetics. They do, 
how^ever, induce a euphoric state which is util- 
ized for preoperative sedation. An additive 
effect is obtained when narcotics are combined 
with less potent anesthetics such as nitrous 
oxide, which thereby facilitates their use. The 
narcotics are almost universally used for con- 
trol of pain preoperatively or postoperatively. 

METHODS OF ADMINISTERING GENERAL 
ANESTHETICS 

Volatile anesthetics are administered by one 
or a combination of four different methods. 

1. The open or drop method, is adaptable for 
liquids. The ^TqulG^ls vapori zed on a gauze 
mesh, becomes mixed with air which serves as 
a vehicle and source of oxygen, and is inhaled. 

2. The i nsufflation technique ( Fig. 1) is suit- 
able for both gases and vapors. A stream of gas 
or vapor, mixed with air or oxygen, is con- 
ducted into the oropharynx, nasopharynx or 
trachea by means of a catheter or a tube. 

3. The semi-rlosed-jnethoid (Fig. 2) is used 
for gases or vapors mixed with air or oxygen. 
A preformed mixture of gases and vapors is in- 
haled from a closed mask which communicates 
with a reservoir (breathing bag). The exhala- 
tions pass through a valve on top of the mask 
provided for the purpose. A directional valve 
interposed between the reservoir and the mask 
prevents return of expired gases and obviates 
rebreathing. 

4. The closed method (Fig. 3) permits total 

rebreathing^^of gases^iad An inhaler 

composed^ oFTmasTand breathing bag is pro- 
vided with a filter containing an absorbent 
(soda lime) for carbon dioxide. Oxygen to 
meet the metabolic requirements of the subject 
is supplied from a reservoir. Both the serai- 
closed and closed types of apparatus must be 
provided with metering devices (flowmeters) to 
supply gases and vapors in desired proportions. 
The closed system is almost universally used 
for the administration of inhalation anesthetics 
in present-day practice. 






Figure 3. Closed or rebreathing technique. The 
closed type apparatus consists of a mask (A) and a 
rubber breathing hag of 4- or 5-liter capacity (C). A 
canister (B) containing soda lime is interposed between 
the mask and breathing bag. In tbe circle filter the 
gases are conducted through the canisters by corru- 
gated tubes. Valves at the inlet and outlet of the canister 
permit a un directional flow. Gases and vapors (D) are 
admitted through an inlet as required. 

Nonvolatile drugs are administered by routes 
other than -inhalation. No satisfactory sub- 
stances exist which can be administered orally 
which induce satisfactory surgical anesthesia. 
Most nonvolatile drugs used in conjunction 
with surgical anesthesia are administered rec- 
tally or intravenously. The narcotics and cer- 
tain of the hypnotic drugs are administered 
subcutaneously or intramuscularly. 

Anesthetics are protoplasmic poisons with 
three notable characteristics: they have a 
special predilection for nervous tissue, they 
ultimately'^'SecrTll protoplasm as concentra- 
tions are increased, and their action is re- 
versible within limits. Once the drug is re- 
moved, the physiologic state of the cell reverts 
to normal. This reversibility of action is ex- 
tremely important. Overdosage of central 
nervous system depressants paralyzes the medul- 



166 


Chapter 7 . 


lary centers. Death results irom respiratory Fail- 
ure. Jlie nervous system is depressed from 
above downward, that is, the cortex first, the 
midbrain next, and then the raecliilla. IF arti- 
ficial respiration is promptly instituted and 
maintained after medullary paralysis occurs, the 
circulatory system remains intact. A dose exists 
for each drug, above that which causes j:)aralysis 
of the medullary centers, which is lethal even 
though effective artificial respiration is per- 
formed. These doses vary From one drug to the 
other. What they arc for man is not known. 
The concentration of ethvl ether which de- 
presses the heart is several times that which 
causes medullary paralysis. On the other hand, 
concentrations of chloroform which depress the 
myocardium are close to those which paralyze 
the respiratory centers. 

1 he progressive depression ol the nervous 
system gives rise to a succession of reflex 
changes which are clinically useful in estimat- 
ing the concentration of the drug in the nervous 
system. The disappearance and reappearance of 
these reflexes, as the concentration is varied, 
serves as a useful guide for the administra- 
tion of anesthetics. The manner in which vola- 
tile drugs influence these reflex changes clifl’ers 
considerably from that of nonvolatile drugs. 
The changes caused by volatile drugs are more 
labile, and more pronounced. Presumably, this 
is due to the inertness of volatile drugs. The 
intracellular concentrations arc closely cor- 
related with blood concentrations. Variations in 
blood concentrations arc quickly reflected in 
the cellular concentration. This does not ap- 
pear to be the case with nonvolatile drugs. 

SIGNS OF ANESTHESIA 

Anesthetic drugs affect all physiologic sys- 
tems to some degree. However, the changes in 
the nervous system, respiratory system and cir- 
culatory system are the most apparent. These 
three systems are under the constant surveil- 
lance of the anesthetist. The character, rate and 
depth of respiration, the pulse and blood pres- 
sure, the reflex changes and the variations in 
muscle tone are all observed closely. 

Four stages of anesthesia are recognized in 
administering volatile drugs. One stage merges 
into the next as the cellular concentrations in- 
crease. There is no abrupt line of demarcation 
between stages. 

In stage I, referred to as the siaze of ane d- 
_gesi^he patient remains consci^s but is un- 
^to_^rceive painful sti n^. Reflexes re- 


Anesthesiology 

main active and the subject attempts to with- 
draw Irom the noxious stimuli, e\'cn though he 
does not interpret them as pain. I'hc sensorium 
remains dear and the subjccl is aware of his 
surroundings. I’his stage is of limited usdul- 
ncss because the jxiticnt is uncooperative. 

Stage 11 is called the stai ie oj (Ic/irinur ll^^ 
cerebral cortex is dc| Hcssccl and ccmiwlui^ 

Jost, Cortical inliibitions arc released as aim 
trol of \’arious centers is lost. The lower, more 
primitive centers then exert tlicir inlkicncc. 

1 his stage is characterized !))■ exaggerated re- 
flexes, iiuarascd.. muscle tone, inx'gLrim "fespira- 
tion, incoodmation, strugghng aiuTcli.surri'nta- 
tion. StiniLi la tion of any sort aggiawates these 
undesirable manifestations. I'.xcbLeincnt is fre- 
quent and signs of sympathetic stimulation arc 
prcscait. ] his stage is not onix of no v'ahic, but 
is one which is avoided and transcended as 
soon as possible, bear and apprehension must 
he allayed and ail manipulations and external 
stimulation held in abeyance until this stage ha.s 
lieen passed . 

Stage III is the stage ol .sa/rg/cx// luicstbcsici. 
Anesthesia is completely established and super- 
ficial reflexes are abolished. Deep reflexes and 
those associated with \dtal functions remain 
active. ^tre absent. Tap- 

ifing the "eyelid no IcmlJcr so-called 

lid reflex. The lid reflex must not lie confused 
with the corneal reflex commonly einplo\-ed by 
physiologists as a guide to depth of anesthesia 
in laboratoiy animals. Ihe corneal reflex is ob- 
jectionable as a guide lor depth oi anesthesia 
because ulcers result from repeated touching 
of the cornea, ihe medull ary centers remain 
active. Respiration is autornliliY rlwabniicaranc! 
resembles that noted in normal sleep l)ecaiisc 
cortical and subcortical influences are abolished 
and it is under sole x'ontroj of the respiratory 
centeis. Pulse and, hlood p ressure, wdiich are 

return to pre 'anes- 
thetic levels. Stage III, since it is broad, is 
subdivided into substages called planes. Stages 
are indicated bv roman numerals; planes by 
arabic numcrals.TIn the first plane tlierc is no 
JossjTjmusclcTone^ movements con- 
tinue are rctractcanmcr light 

enters the pupil. These ocular movements dis- 
the smaller muscles 
throughotittficbody, including those of the 
eye, lose their tone. The pupils are, then, cen- 
trally fixed. Respiration is altered little in planes 
1 and 2 because both the intercostal muscles 
and the diaphragm remain active. As plane 3 is 



General Anesthetics 


167 


leached, inte rcostal activity is lost and respira- 
tion becomesdiaphragmatic*lir^^ iuscle 
tone is diminishe d ^throughout the bodv. The 
size but are not widely 
ed. Corneal reflexes are obtunded or abol- 
ished. There may be some ele vmi o jy in pi 1 1 se 
rate and a sli g ^Fall in blood pressure. Surgerv 
necessitating reExatiori~"”of if)^ large muscles 
may be performed in plane 3. In plane 4, com- 
plete jhe large j nuscles and loss 

of al l reflexes occur. DiaphragmaticTHix'itv is 
dimirnS37TKTpufilTare widely dilated. Res- 
piration is diaphragmatic, inspiration is quick, 
short and jerky and expiration is prolonged. 
The minute volume exchange is diminished. 

In stage IV, the medullary centers are in- 
active. The respi ratory center is the first of the 
medullar y centers to become completely de- 
pressed an d a^nea resu lts. Unless artificial res- 
piration is instituted promptly, death results 
from the ensuing asphyxia. With most of the 
anesthetic drugs employed, the heart continues 
to beat after the onset of this stage if artificial 
respiration is instituted and maintained as soon 
as apnea occurs. 

The cough reflex disappears as stage III is 
reached. The vomiting or gag reflex disappears 
at the same time. Tracheal and bronchial re- 
flexes disappear in planes 2 and 3. Reflexes 
initiated by traction on the abdominal viscera, 
pleura, hilum, trachea, or bronchi or by stimula- 
tion of the perineal structures disappear in 
plane 3 but may persist even into plane 4. 
When the anesthetic is discontinued reflex ac- 
tivity returns in the reverse sequence. After 
the administration of ether for a long period, 
however, the order of return of reflexes is 
variable. Anoxia, carbon dioxide excess, heavy 
sedation and basal narcosis with nonvolatile 
drugs modify and invalidate the signs. The 
signs tend to vary with the extremes of age. 

ABSORPTION AND ELIMINATION OF 
ANESTHETICS 

The absorption and elimination of volatile 
anesthetics are influenced by the following fac- 
tors: (1) the tension of concentration in the 
inspired mixture, (2) the tidal exchange, (3) 
the minute volume exchange, (4) the func- 
tional residual air volume, (5) the solubility 
coefficient of the drug in blood, (6) the rate 
of diffusion through the alveolar membrane, 
(7) the minute volume blood flow through the 
lungs, (8) the blood flow through the tissues 
and (9) solubility in the tissues, 


A pressure gradient is established from the 
inspired gases to the blood and thence to the 
cells. Obviously, the higher the gas tension in 
the blood, the greater the pressure gradient 
betv\een it and the ceils and the more rapid the 
saturation of the tissues. An adequate tidal ex- 
change is necessary to allow proper mixing of 
the gas or vapor with the functional residual 
air. The functional residual air volume is im- 
portant because it represents the total gas \'ol- 
ume which comes into contact with the alveoli 
and which mixes with tidal air. When the 
functional residual air volume and the tidal 
volume are about the same, the changes in 
ahuolar concentration with each respiration are 
abrupt. This situation is encountered in chil- 
dren. A momentary increase or decrease in 
concentration is immediately reflected in the 
blood level and anesthesia lightens or deepens. 
If the functional residual air volume increases 
out of proportion to the tidal exchange, mixing 
does not occur. Saturation and desaturation 
are impaired and take more than the usual 
time. An increase in minute volume exchange 
facilitates tissue saturation by increasing the 
total quantity of drug carried to the lungs. 

Volatile anesthetics diffuse through the 
ahuolar membrane in the same manner as do 
other gases and vapors. The drug does not alter 
the membrane; otherwise it would be unsuitable 
clinically. Volatile anesthetics are often referred 
to as irritating, the inference being that the 
alveolar membrane is in some way injured. 
This is not so. Most v^olatile drugs, particularly 
ether, stimulate the vagal nerve endings in the 
pulmonary tissues and cause exaggerated 
breathing. Also the mucous glands in the re- 
spiratory tract are stimulated and excessive secre- 
tions accumulate. Both responses are mistakenly 
interpreted as “irritation.” 

INHALATION ANESTHETICS 

Nitrous Oxide. Nitrous oxide, often re- 
ferred to as 'gas,'' is a nonirritating, sweet-smell- 
ing, nonflammable gas of mild narcotic potency. 
It rarely yields anesthesia deeper than the first 
plane. The ah^eolar tension for surgical anes- 
thesia varies betw^een 625 and 650 mm. Hg 
(80 to 85 per cent). Induction and recovery 
are rapid—approximately three minutes. Ni- 
trous oxide is not suitable for operations requir- 
ing profound anesthesia or muscle relaxation. 
Its effectiveness is increased when combined 
with morphine or other narcotics, basal narcosis 
induced with Avertin or thiopental, ether, vinyl 



168 


Chapter 7 . Anesthesiology 


ether, chloroform or trichlorethylene or the 
muscle relaxants. Unless thus fortified, sub- 
oxygenation invariably occurs. Overdosage does 
not occur if the gas is administered at atmos- 
pheric pressure with more than 20 per cent 
oxygen. 

Nitrous oxide is an effective analgesic. An 
alveolar tension of 365 to 380 mm. Hg (35 to 
50 per cent) causes a high degree of analgesia. 
Its use as an analgesic is limited because little 
surgery can be performed effectively with anal- 
gesia. Nitrous oxide is used as an induction 
agent for ether anesthesia and in combination 
with basal narcotics in situations in which 
cautery, endotherms, endoscopes or other equip- 
ment w^hich may be a fire hazard are required. 
It is also used for analgesia for obstetrical or 
dental surgery. Nitrous oxide is administered 
by means of semi-closed inhalers in order to 
permit the elimination and replacement of 
nitrogen from the blood and tissues by the gas. 
Without anoxia the drug disrupts none of the 
important vital functions. Desirable features 
are that it is nonflammable, nonirritating to the 
respiratory tract, relatively inexpensive and 
rapidly absorbed and eliminated. Postanesthetic 
nausea and emesis are infrequent. There is no 
justification in using the drug if anesthesia 
cannot be obtained without anoxia. Most fatali- 
ties caused by nitrous oxide are due to asphyxia. 
When administered in nonasphyxial concentra- 
tions, there are no contraindications to its use. 

Ethylene. Ethylene is a nonirritating, flam- 
mable, gaseous hydrocarbon with an ethereal 
odor and a mild narcotic potency. Pharma- 
cologically, it is similar to nitrous oxide. Anes- 
thesia is characterized by rapid induction and 
recovery. The depth attained is rarely lower 
than plane 1 or the upper limits of plane 2. An 
alveolar tension of approximately 540 mm. Hg 
(75 per cent) is necessary for anesthesia. Well- 
premedicated subjects require less. As is the 
case with nitrous oxide, respiratory failure 
occurs only when anesthesia is complicated by 
anoxia. Fatalities are due to asphyxia. As is the 
case with nitrous oxide, narcotics, the basal 
narcotics, ether, vinyl ether or tricholorethylene 
are used as fortifying agents. Alone, it is suit- 
able for operations requiring pain relief with- 
out muscle relaxation. Ethylene is nonirritating 
to the respiratory tract, and, like nitrous oxide, 
causes no significant physiologic disturbances 
if adequate oxygenation is maintained. It is 
used for induction of ether anesthesia. The 
chief objection is that it is flammable. The 


technique of administration is the same as that 
used for nitrous oxide. It is somewhat more po- 
tent than nitrous oxide in comparable cireLim- 
stances. 

Cyclopropane. Cyclopropane (trimethy- 
lene) is a stable, flammable, pleasant-smelling, 
easily inhaled, nonirritating, gaseous hydrocar- 
bon. Induction of anesthesia is rapid, retfiiiring 
three or four minutes. Most of the gas, irrespec- 
tive of the length of operation, is eliminated 
within ten minutes. Recovery of rcllcx activity 
occurs promptly in the operating room. All 
stages arc traversed. When overclosage occurs 
respiratory failure precedes circulatory failure. 
Muscle relaxation adequate for abdominal sur- 
gery may be obtained without the use of ad- 
juncts if one chooses. Muscle relaxants, such 
as curare and the synthetic relaxants, permit 
use of the upper planes of anesthesia. The 
drug is more potent than ethylene and nitrous 
oxide. A tension of 150 to 175 mm. I Ig (20 
to 25 per cent) in the alveoli is ncces,sary for 
surgical anesthesia. Respiratory failure results 
when the tension is about 300 mm. Hg (40 
per cent). The margin of safety, therefore, is 
wide. Anoxia is no problem because 20 per 
cent or more oxygen may be used at all times. 
The closed .system with total rebreathing is 
used to administer the gas since it is highly 
potent and nitrogen need not be eliminated 
from the system. This is an advantage in view 
of the high cost and flammability. Anesthesia 
may be lightened and deepened quickly and 
at will. This is a distinct advantage in manage- 
ment of poor surgical risks. 

Metabolic processes are not significantly dis- 
turbed. A slight insignificant elevation of blood 
glucose occurs, but there is no effect in the 
carbon dioxide combining power, liver or renal 
function. 

Respiration is depressed, as a rule. The mi- 
nute volume exchange is reduced, but in spite 
of this the arterial and venous blood arc normal- 
ly saturated with oxygen. A respiratory acidosis 
results from carbon dioxide retention owing to 
this hypoventilation. The most objectionable fea- 
ture of the drug is the increase in cardiac ir- 
ritability which causes arrhythmias. These may 
be ventricular in origin. Ventricular fibrillation 
may occur if epinephrine is used in conjunction 
with cyclopropane, because both drugs increase 
cardiac irritability. Myocardial depression does 
not occur and cardiac output is decreased only 
during deep anesthesia. An elevation in Mood 
pressure is often noted during operation 'which 



General Anesthetics 


169 


is due to carbon dioxide retention. Postanes- 
thetic nausea and vomiting are less frequent 
than with ether, but they do occur. At the con- 
clusion of anesthesia, a hypotension is some- 
times noted which is associated with the re- 
spiratory acidosis. At times excessive oozing of 
blood in the wound occurs. This is due to the 
elevation in blood pressure and a local periph- 
eral vascular dilatation. Bleeding and clotting 
times are not disturbed. 

Vinyl Ether. Vinyl ether (Vinethene) is a 
highly volatile, flammable, liquid which boils 
at room temperature (28® C.). The vapor is 
nonirritating, easily inhaled and quickly pro- 
duces surgical anesthesia. The drug is the un- 
saturated counterpart of ethyl ether. It is less 
stable than ether. Approximately 30 to 40 mm. 
Hg (4 per cent) are necessary in the alveoli 
for anesthesia; 60 mm. Hg (8 per cent) for 
respiratory failure. The drug is used as an in- 
duction agent for ether anesthesia by the open 
mask technique and for analgesia for minor 
surgical procedures. It is also used as a com- 
plemental agent to fortify nitrous oxide or 
ethylene. Vinyl ether is administered by the 
open drop method in short surgical procedures 
or in combination with nitrous oxide by the 
semi-closed method. The closed method is not 
satisfactory because difficulty is encountered in 
maintaining an even plane of anesthesia. Even 
though stage IV can be attained, relaxation is 
not adequate for major surgery. Induction and 
recovery are rapid (two to three minutes) and 
pleasant. Postanesthetic nausea and vomiting 
are infrequent. Vinyl ether is not chemically 
stable unless an inhibitor is added and the drug 
is protected from light, heat and air. 

No clinically significant physiologic and 
metabolic disturbances occur during anesthesia. 
Hepatic or renal damage does not occur unless 
this agent is administered repeatedly or if ad- 
ministration is accompanied by anoxia. Vinyl 
ether is not used for procedures of over thirty 
minutes, or for those requiring muscle 
relaxation. The drug is not used when hepatic 
or renal disease exists. Excess secretions may 
help disseminate and thereby aggravate an 
acute upper respiratory infection. 

Ether. When doubt exists concerning se- 
lection of an anesthetic, ether, in spite of al- 
leged shortcomings, still remains the safe and 
reliable choice. Ethyl ether is a volatile, flam- 
mable, liquid whose vapor possesses marked 
narcotic potency. The vapor is heavier than 
air, pungent and induces coughing when in- 


haled in anesthetic concentrations without 
previous acclimatization. Ether is suitable for 
major surgery requiring muscular relaxation. It 
possesses a wide margin of safety. The alveolar 
tension necessary for surgical anesthesia is ap- 
proximately 30 mm. Hg (4 per cent), for 
respiratory failure 60 mm. Hg (8 per cent). 
This wide margin of safety is one of the de- 
sirable features of ether. 

Ether is administered by open masks, using 
air as a vehicle, by the insufflation technique 
using air or oxygen as a vehicle, by the semi- 
open inhaler with nitrous oxide, or by means of 
closed inhalers with oxygen. The induction 
period is unusually long because of the pungent 
irritating effects and because of the marked 
capacity of the body for the drug. Ether, com- 
pared to other volatile anesthetics, is water 
soluble and the body is capable of absorbing 
a considerable quantity. Besides, it has a high 
blood-air coefficient (15:1) so that partition 
between blood and alveolar air is slow. The 
elimination requires many hours on this ac- 
count. The time for complete elimination thus 
varies with the duration and depth of anes- 
thesia. To simplify and shorten induction, a 
nonirritating, rapid-acting drug, referred to as 
the induction agent, is first used. The drug 
used for induction is nitrous oxide, ethylene, 
cyclopropane, vinyl ether, chloroform or ethyl 
chloride. As soon as anesthesia is induced with 
the preliminary agent, the anesthetic concentra- 
tion of ether is delivered. This can be done 
more rapidly than would be possible if the 
ether were given directly. The first and second 
stages thereby are shortened. 

Ether is relatively inexpensive, is chemically 
stable, easily preserved, and is administered by 
simple apparatus when necessary. The assertion 
that the open drop technique is the best for 
ether is fallacious. In an emergency, it is the 
safest technique to use by inexperienced indi- 
viduals provided the drug is given under the 
surveillance of an experienced anesthetist or 
surgeon. Air may be used as a diluent and as 
the source of oxygen because the tension re- 
quired for anesthesia is low. At ordinary levels 
of anesthesia, ether exerts few deleterious ef- 
fects upon the circulatory system. Respiratory 
movements are exaggerated owing to stimula- 
tion of the alveolar vagal nerve endings by the 
vapor. Nausea and vomiting are common in the 
postanesthetic period. Liver function, acid-base 
balance and carbohydrate metabolism are tem- 
porarily disturbed. Acidosis from any cause is 



170 


Chapter 7 . Anesthesiology 


enhanced by ether anesthesia. Ether should be 
avoided in an acute respiratory infection. It is 
contraindicated in syndromes of the brain ac- 
companied by increased intracranial pressure 
because it often causes a further increase in 
pressure. 

Ethyl Chloride. Ethyl chloride is a highly 
volatile, flammable liquid whose vapor is pleas- 
ant smelling, easily inhaled and produces surgi- 
cal anesthesia. Chemically it is a stable halo- 
genated hydrocarbon. Analgesia results when 
the alveolar tension is 1 5 to 20 mm. I Ig (2 to 
3 per cent), anesthesia at 30 to 33 mm. Elg. 
Induction and recovery are rapid, usually re- 
quiring two to three minutes. It is used as an 
induction agent to shorten the first and second 
stage of ether anesthesia administered by the 
open mask techniques and for anesthesia and 
analgesia for operations for minor surgical pro- 
cedures of not more than several minutes’ dura- 
tion. Ethyl chloride ordinarily is administered 
by the open drop method. Air acts as both the 
vehicle and as a source of oxygen. 

Ethyl chloride does not cause respiratory 
depression. Cardiac arrest may result from 
direct depression of the myocardium. Besides, 
it increases cardiac irritability and causes seri- 
ous arrhythmias. Ventricular fibrillation may 
occur early in anesthesia. Asystole may occur 
before medullary paralysis. For this reason, the 
use of the drug is not advised for any proce- 
dure. Anesthesia, at times, is accompanied by 
stridor or muscle rigidity. The depth of anes- 
thesia is difficult to maintain at a constant level 
because of the high volatility. Postanesthetic 
nausea and vomiting are uncommon. 

Chloroform, Chloroform (trichlormethane) 
is a colorless, volatile liquid whose vapor is 
sweet smelling, easily inhaled and nonflam- 
mable. It is the most potent of the inhalation 
anesthetics. All types of surgery requiring 
muscle relaxation may be performed with 
chloroform anesthesia. Chloroform is unsafe 
because it is cardiotoxic and hepatotoxic. It has 
been used as an induction agent for shortening 
stage II of ether anesthesia, as an analgesic for 
obstetrics in dilute concentrations and in situa- 
tions in which a fire hazard exists. Surgical 
anesthesia results with alveolar tensions of 5 to 
8 mm. Hg (1.5 per cent) and respiratory fail- 
ure with 15 to 16 mm. Hg (2 per cent). The 
margin of safety is narrow. Induction of anes- 
thesia is rapid. Preliminary agents, such as 
nitrous oxide or ethylene, are not required. 
Chloroform has been used in tropical areas be- 


cause it is less \’olatiie than are other drugs. As 
in the case of ether, simple cc]uifuiicnt (open 
masks) may be used for administraLion. Exag- 
gerated breathing results hut to a lesser extent 
than that caused by ether. The extreme potency 
and low partial pressure nceessary lor anes- 
thesia permit the use of air as a sourec of 
oxygen and as a v'chicle in OjX'n methods. 

Chloroform exerts a dual effect on the heart 
by depressing the myocardium and increasing 
irritability of the conductive tissues. Cardiac 
output is reduced as anesthesia deepens. Ven- 
tricular fibrillation occurs if epinephrine is 
given during chloroform anesthesia. /Vt the 
point of respiratory failure, myocardial depres- 
sion may proceed to asystole, and one is then 
confronted by twx) emergencies in such an 
event. Liver function is depressed more with 
chloroform than with any other volatile agent. 
Besides, hepatitis may occur posto[X‘ratively 
from a direct toxic effect on liver cells. Elevation 
of blood sugar, alteration in acid- base balance, 
and dehydration occur, and the prothrombin 
time is prolonged. Phosgene forms when vapors 
are exposed to flames or cautery. Postancsthctic 
nausea and vorinting are frccjiient. Diseases of 
the heart, hypertension, hypotension, liver and 
renal derangement and diseases of the respira- 
tory tract are contraindications to the use of 
chloroform. 

Trichlorethylene. Trichlorethylenc (Tri- 
lene) is a colorless, heavy liquid. It is an un- 
saturated halogenated hydrocarbon-ethylene 
with three hydrogen atoms replaced by chlo- 
rine. The odor resembles that of chloroform. 
Waxoline blue is added to avoid mislaking one 
for the other in localities where both drugs arc 
used. Oxidation converts the drug to phosgene. 
The open or semi-closed techniques are used 
for its administration. The closed system can- 
not be used because soda lime converts the drug 
to dichloracetylene which is ncurotoxic. Mix- 
tures of trichlorethylene and oxygen (10 per 
cent) are combustible but in the concentration 
used for surgical anesthesia are not flammable. 

Alveolar tensions of 25 to 30 mm. Jig (41 
per cent) are anesthetic. The tension necessary 
for respiratory failure has not been established. 
Respiratory failure precedes circulatory failure 
when overdosage occurs. Tensions of 2 to 8 
mm. Hg (0.25 to 1.0 per cent) are analgesic. 
Most of the drug is exhaled unchanged, but 
some is transformed to tricliloreacetic acid by 
the liver and excreted into the urine. 

Induction is slow and resembles that of 



Endotracheal Anesthesia 


111 


ether. Analgesic concentrations are not irritat- 
ing but anesthetic concentrations cause exces- 
sive salivation and secretion of mucus. Trichlor- 
ethylene causes a tachypnea by stimulating the 
vagus nerve endings. The respiratory rate may 
exceed 60 per minute at times, Trichlorcthy- 
lene depresses the myocardium and increases 
cardiac irritability. It is used for analgesia but 
is not recommended for surgical anesthesia. 
Besides being toxic, it produces relaxation of 
skeletal muscle that is not adequate for major 
surgery. It is important to differentiate between 
analgesia and anesthesia. Inhalers are available 
for self-administration of the drug to provide 
analgesia for minor procedures. Trichiorethy- 
lene is used to fortify nitrous oxide. 

ENDOTRACHEAL ANESTHESIA 

Endotracheal anesthesia consists of introduc- 
ing a catheter into the trachea through the 
mouth or nose and conducting the gases and 
vapors directly from the apparatus to the lungs. 
Actually, the catheter extends or prolongs the 
trachea to the lips or nares. During general anes- 
thesia, the muscles of the neck, tongue, pharynx 
and jaw are relaxed and the tongue sags back- 
ward. As they do so, the epiglottis swings posteri- 
orly and occludes the pathway into the trachea 
and respiratory obstruction results. A properly 
placed catheter provides an unimpeded airway. 
In addition, it permits the anesthetist to employ 
positive pressure and artificial respiration when 
indicated. 

A catheter of smaller diameter may he passed 
into the tracheal catheter to aspirate secretions. 
The endotracheal catheter prevents laryngeal 
spasm by keeping the cords abducted. Certain 
surgical manipulations such as incising the 
periosteum, making traction upon the organs in 
the abdomen and thorax, dilating the rectum, 
or stimulating the perineal structures excites 
reflexes which cause laryngeal spasm. The 
catheter prevents the spasm, A properly intro- 
duced endotracheal catheter prevents aspiration 
of vomitus. The catheter assures an airway for 
patients undergoing surgery in the prone or 
lateral positions as in the cases of operations 
upon the vertebral column, back and head, or 
thorax. In surgery of the mouth, pharynx, and 
larynx an endotracheal tube allows the anesthe- 
tist to be out of the operative field and still have 
control of the airway. Endotracheal anesthesia 
is necessary for obese individuals and others in 
wTom an open airway is maintained with diffi- 
culty. 



Figure 4. Closed oral endotracheal anesthesia is 
accomplished by connecting an intratracheal catheter 
(^A) equipped with an infiatable cuff to an adaptor 
which replaces the mask of a circle filter. An entirely 
closed system is obtained. Anesthesia is conducted in 
the same manner as it would he if a mask were used. 
(From Adrian! : Techniques and Procedures of Anes- 
thesia. Courtesy Charles C Thomas, Publisher.) 

The catheter is introduced by direct laryn- 
goscopy, that is, the lar}'nx is visualized directly 
with a laryngoscope. When the catheter is in- 
troduced through the mouth, the procedure is 
called "oral endotracheal intubation." In nasal 
intubations, the catheter is introduced through 
the nostril which is most patent and free from 
obstruction. The curvature of the catheter and 
the anatomic position of the larynx favor pas- 
sage into the trachea without laryngoscopy. 
This procedure is called "blind nasal intuba- 
tion.’’ When the catheter cannot be passed 
blindly, the larynx is exposed with the laryn- 
goscope and the tube is introduced under 
direct vision with a forceps. 

If, in the oral technique, the mask is replaced 
over the mouth after intubation the technique 
is called “open oral endotracheal anesthesia.” 
If the catheter is introduced nasally and the 
mask is replaced over the nose and mouth, the 
technique is known as “open nasal endo- 
tracheal intubation.” The catheter may be con- 
nected directly to a closed or semi-closed in- 
haler. When this is done, the technique is 
called “closed endotracheal anesthesia” (Fig- 
4). Sometimes an inflatable cuff or a gauze 
pack is used to seal the space between the wall 
of the trachea and the catheter and provide a 
leak-proof closed system. Catheters are made of 
rubber, plastic or metal. Wire coils are often 
incorporated in the wall of rubber catheters to 
prevent kinking. 

Endobronchial anesthesia consists of intro- 



172 Chapter 7. 

ducing a longer, special catheter into the 
bronchi. Endobronchial catheterization is usu- 
ally employed for partial or complete pneumo- 
nectomy for suppurative diseases of the lungs 
to prevent secretions from passing from the dis- 
eased to the healthy lung. Catheters used for 
differential bronchospirometry are also suitable 
in these circumstances. Each division passes in- 
to the right and left bronchus respectively and 
anesthesia is conducted and aspiration accom- 
plished in each lung separately. 

For intubation, general anesthesia is induced 
in the usual manner with cyclopropane, ether 
or other drug until the neck and jaw muscles 
relax. The larynx is then exposed and the 
catheter inserted. A muscle relaxant facilitates 
the intubation. Unless performed by skilled 
operators, considerable trauma may result to the 
pharynx, larynx and trachea which may be 
followed by serious consequences. The advan- 
tages of endotracheal anesthesia outweigh most 
disadvantages. Difficulties encountered, as a 
rule, are due to poor technique. 

In certain surgical procedures, apnea is delib- 
erately induced and respiration is maintained ar- 
tificially to provide a quiet operative field. Such 
operating conditions facilitate intrathoracic and 
upper abdominal operations. Ventilation, refer- 
red to as 'Controlled respiration,"' is maintained 
by rhythmic compression of the breathing bag 
of the anesthetic apparatus approximately 
twenty times per minute. Apnea is induced by 
using a drug which depresses the respiratory 
center, usually a nonvolatile drug and cyclo- 
propane. The overdistention of the alveoli to 
excite the Hering-Breuer reflex to inhibit in- 
spiration and hypocapnia caused by hyperven- 
tilation also contributes to the development of 
the apnea. Some anesthetists cause the apnea 
by curarizing the patient to the point of com- 
plete muscle paralysis. The effect of increased 
pressure on the airway for long periods of time 
may bring about a reduction in cardiac output 
and circulatory deterioration during controlled 
respiration no matter how it is induced. 

BASAL NARCOTICS 

Ethyl Alcohol. Ethyl alcohol is not satis- 
factory for surgical anesthesia because it does 
not completely abolish the reflexes and it pos- 
sesses a narrow margin of safety. The concen- 
tration necessary fox anesthesia, in a surgical 
sense, approximates that which causes medul- 
lary depression. The systemic effects are the 
same regardless of the route of administration. 


Anesthesiology 

Ethyl alcohol is administered intravenously (5 
per cent with 5 per cent dextrose in distilled 
water) for analgesia postoperative! y, or for 
sedation preliminary to anesthesia for addicts 
or patients who cannot be gi\’eii narcotics For 
other reasons. 

Paraldehyde. Paraldehyde is a colorless, 
mobile, liquid possessing a pungent odor which 
appears to cling to surrounding objects for clays. 
The drug is a polymer of aeetaldelncle. It is 
used as a hypnotic for alcohol addicts and men- 
tally disturbed patients or as a basal narcotic 
preliminary to surgery. Its use as an amnesic 
agent for obstetrics has also been described but 
is not advised. Paraldehyde possesses anticon- 
vulsant properties. The drug is tidminislcred 
rectally or intravenously. Like other nonvolatile 
substances, it lacks analgesic properties and the 
ability to abolish reflexes completely. It is 
characterized by a variability of action. The 
drug causes irritation of the mucosa of the 
mouth, stomach and rectum. Basal narcotic 
doses disturb metabolic processes. An elevation 
in blood sugar and lowering of carbon <lioxidc 
combining power are frequentA observed. 
Some of the drug is exhaled through the lungs 
but the bulk of it is detoxified by the liver. 
Paraldehyde is not used when pulmonary dis- 
eases or hepatic or renal insudiciency exist. 

Tribromethanol (Avertin). 'Tribronietha' 
nol, a halogented derivative of ethyl alcohol, 
is a white crystalline substance with an ethereal 
odor. The drug is poorly soluble in water hut 
very soluble in amylene hydrate (tertiary amyl 
alcohol). The latter is used as a vehicle to pre- 
pare a solution used in clinical medicine known 
as Avertin fluid. One cubic centimeter of 
Avertin fluid contains 1000 mg. of the drug 
and 500 mg. of the solvent A 3 ])er cent solu- 
tion in water (27 to 36 mg. per lb. of body 
weight) is administered rectally forty-fi\'e min- 
utes before induction of anesthesia, llie drug 
is ineffective orally; its action intravenously is 
variable. Following rectal administration, a deep 
stage of hypnosis accompanied by amnesia 
develops within five minutes. Reflexes are not 
completely abolished, however, and surgery 
cannot be performed without a supplemental 
anesthetic such as a nerve block, cyclopropane, 
nitrous oxide or ether. The drug is conjugated 
with glycuronic add by the liver and the 
product is excreted by the kidneys. Avertin is 
used to control convulsions and other hyper- 
irritable states of the nervous system such as 
axe encountered in tetanus, rabies or drug re- 



Basal Narcotics 


173 


actions. Recovery from hypnosis is gradual over 
a period of several hours. Prolonged amnesia 
results. Avertin is administered at the bedside 
to allay apprehension preoperatively. It thus 
eliminates excitement during induction of in- 
halation anesthesia. Tribromethanol is nonirri- 
tating to the respiratory tract but does depress 
respiration. Postoperative nausea and vomiting 
are minimized and the amount of supplemental 
anesthetic necessary is reduced. It is noncon- 
trollable, however; once a dose is administered 
it cannot he retrieved. The exact dose is diffi- 
cult to estimate owing to variations in suscepti- 
bility of the individual and absorption from the 
rectum. Hypotension due to depression of the 
vasomotor center is frequently obser^^ed. Re- 
peated doses result in cumulative effects. 
Laryngeal and pharyngeal reflexes are partly 
obtunded and are reactivated by stimulation. 
Constant attendance of the patient is required 
from the moment the drug is administered until 
narcosis has receded. Proctitis and colitis may 
result from use of deteriorated solutions. The 
drug is not stable and deteriorates if solutions 
are heated or allowed to stand. Hepatic and 
renal diseases, “toxemia^ sepsis, acidosis, shock 
or other forms of hypotension, dehydration, low 
metabolic rate, chronic pulmonan^ disease, dis- 
ease of the gastrointestinal tract, amnesia and 
chronic alcohol addiction are contraindications 
to the use of the drug. 

Barbiturates. One of the most useful 
groups of drugs in medicine is the barbiturates. 
The barbiturates possess no significant analgesic 
properties and cannot, therefore, be used alone 
for pain relief. Barbiturates are placed into four 
groups, namely, the long acting, the interme- 
diate acting, the short acting and the ultra- 
short acting. The long and intermediate acting 
derivatives are used for sedation. The short 
acting and ultra-short acting are used in con- 
junction with surgical anesthesia as basal nar- 
cotics. Barbiturates are usually given intrave- 
nously when used for basal narcosis. The rectal 
route is used for children. The ultra-short act- 
ing derivatives are more potent than the short 
acting. All barbiturates manifest a latent period 
from the moment of injection until the peak 
effect is attained. The latent period is briefest 
and the peak effect most intense with the ultra- 
short acting drug. Thiopental (Pentothal), 
thiosecoharhital (Surital) and hexoharbital 
(Evipal) are the most important currently used 
derivatives. A dilute solution of any of these 
injected intravenously causes unconsciousness 


within thirty-fi\ e or forty seconds. These com- 
pounds pass quickly from the blood and are 
stored in the lipoid and other tissues. Recovery 
occurs when the Mood level falls. Fractional 
doses are administered at frequent intervals in 
order to maintain basal narcosis. In due time 
enough of the drug accumulates in the adipose 
tissue to maintain a sustained depressed state. 
Reflex activity is not completely abolished dur- 
ing barbiturate narcosis. The patient does not 
respond, however, unless stimulated. Painful 
stimuli often cause the patient to become partly 
roused into a delirious, unruly state. It is cus- 
tomary in present-day practice to combine bar- 
biturates with an analgesic, usually nitrous 
oxide. Neither the barbiturate nor the nitrous 
oxide yields satisfactory muscle relaxation. This 
is obtained by adding a muscle relaxant. 

Barbiturates cause depression of the medul- 
lary centers. Hypotension, due to depression of 
the \’asomotor center, is not uncommon after 
intravenous administration. A cumulative ac- 
tion invariably occurs when fractional doses are 
administered over a long period of time. The 
barbiturates are, therefore, used at the begin- 
ning of anesthesia to facilitate induction or for 
short procedures. The laryngeal, pharyngeal 
and bronchial reflexes remain active. In fact, 
the thiobarbiturates enhance the activity of 
these reflexes and intense bronchial and laryn- 
geal spasm are initiated by stimulation of the 
upper respiratory passages. Mucus, blood, or 
surgical manipulation in the respiratory tract 
may give rise to serious difficulties. The effec- 
tive dose varies with the susceptibility of the 
individual. As a rule, 1.0 gm. is the average 
dose for an adult. Recovery after short proce- 
dures is prompt. Detoxification occurs in the 
liver. The rate depends on the total amount 
injected and the metabolic state of the patient. 

Aqueous solutions of salts of barbiturates are 
alkaline. Phlebitis and thrombosis may occur 
after intravenous administration. Induction of 
basal narcosis is rapid and pleasant with intra- 
venous barbiturates. Secretions are absent in 
contradistinction to the volatile anesthetic 
drugs. The barbiturates are the only agents 
which may be used in areas where a fire hazard 
exists, particularly w^hen the anesthetic is to be 
combined with nitrous oxide. Nausea and 
vomiting are uncommon following the use of 
barbiturates. The ultra-short acting barbiturates 
are not desirable for patients at the extremes of 
age, in hypotensive states (shock), or for those 
who have any of the anemias or any disease of 



Chapter 7 . Anesthesiology 


the lespiratory tract characterized by dyspnea, 
hypo\ttitilation, excessive secretions due to 
suppuration, or reduction in pulmonary func- 
tion, 

NARCOTICS 

i hc narcotics are nonvolatile drugs which 
possess both analgesic and hypnotic properties. 
Most narcotics induce a psychic response often 
termed, “a sense of well-being’’ or “euphoria.” 
[Narcotics obtiind dull aching types of pain 
more effectively than the sharp, lancinating 
types. Unless large doses are used, reflex activ- 
ity is not abolished. The narcotics, therefore, 
are suitable only for relieving pain preopera- 
tively or postoperatively or after trauma, but 
not for producing surgical anesthesia. The feel- 
ing of well-being and the air of indifference 
induced by narcotics make them superior to 
other drugs for preanesthetic medication. Bar- 
biturates and other hypnotics do not as a rule 
induce this response and are, therefore, used 
less frequently for psychic sedation preliminary 
to surgery. 

Until recent years the only useful narcotics 
were opium derivatives. Synthetic narcotics are 
now available. Qualitatively, they are similar 
to opium derivatives, but quantitatwely they are 
different. Meperidine (Demerol), methadon, 
methyl morphinan (Dromoran) and alpha-pro- 
dine (Nisentil) are suitable analgesics but less 
effective as preanesthetic medicaments. The opi- 
um alkaloids are derived from phenathrene. The 
most important of these, of course, is morphine. 
Modifications of the morphine molecule yield 
codeine and dihydromorphinone (Dilaudid). 
Tolerance and habituation quickly result when 
narcotics are administered repeatedly over a 
period of time. After several weeks physical 
dependence (addiction) develops. In addition, 
the drug is required to maintain necessary cellu- 
lar functions and withdrawal results in the 
abstinence syndrome, the symptoms of which 
suggest an organic disease. 

MUSCLE RELAXANTS 

Muscle relaxants are nonanesthetic sub- 
stances used as adjuncts to anesthesia. They act 
by interfering with the transmission of impulses 
from peripheral nerves to striated muscle. They 
do not block the nerve or depress the muscle 
fibers. They are nonhypnotic and nonanalgesic. 
Two types are recognized: thos e which preven t 
a cetylcholine JxaHar^a ^ at tETreceptomm gan 
oFtEeTnuscle fiber and those which cause a 


persistent depolarization of the membrane at 
the receptor substance. 

Curare was, at one time, the most widely 
used muscle relaxant. The active principle in 
curare is the alkaloid tubocurarinc. Synthetic 
substances are now used, the most important of 
which are decamethon ium and s ucci nydcho- 
line. Curare and tubocLirarine inhibit acetyfi 
cholinc; decamethonium and succinylcholinc 
cause persistent depolarization. Succinylcholinc 
is rapidly hydrolized by cholinesterase, its ac- 
tion, therefore, is fleeting and sustained relaxa- 
tion can only be obtained by continuous infu- 
sion. 

When relaxation is desired, the clrtig is ad- 
ministered intravenously. Complete muscle 
paralysis may be secured during which respira- 
tion must be obtained artificially. By control- 
ling dosage, paresis of large muscles without 
apnea results. The action of curare lasts fifteen 
to twenty minutes after which time the dose 
must be repeated. The combination of nitrous 
oxide, a muscle relaxant, and basal narcosis, 
using an ultra-short acting barbiturate (thio- 
pental), is widely used. 

LOCAL AND REGIONAL ANESTHESIA 

Regional, or conduction, anesthesia is em- 
ployed when one wishes to obviate the risks, 
disadvantages and discomforts of general anes- 
thesia. Regional anesthesia is subdivided into: 
0) s pinaLhlock in which the drug is intro- 
ducea in the subarachnoid space and exerts its 
effect on the spinal nerve roots, (2) t xua dural 
block in which the drug is applied in the peri- 
dural space, (3) nerve block in which the drug 
is applied directly to a nerve, (4) ficIcM fl^^ in 
which a group of nerves is blocked as each 
branches from a main trunk, (5) infiltration , in 
which the tissues at the surgical TiuTare^ 
trated so that each individual nerve ending is 
blocked by disseminating a solution over a wide 
area, and (6) ^jxipkafi^in which the drug is 
applied on a mucous membrane through which 
it penetrates and anesthetizes the ner^'e ending 
beneath it. 

Local Anesthetic Drugs. Numerous drugs 
are available for conduction anesthesia. In order 
to be of practical value for blocking or conduc- 
tion anesthesia, a drug must possess the follow- 
ing qualities: (1) the ability to produce an 
adequate intensity of anesthesia within several 
minutes, (2) the capacity to give an effect 
lasting long enough to permit successful com- 
pletion of the operation, (3) the inability to 



175 


Local and Regional Anesthesia 


cause local irritation immediately, after injec- 
tion, or in the postoperative period, (4) the 
inability to produce local tissue damage or to 
retard healing, (5) low systemic toxicity, and 
(6) compatibility with vasoconstrictors such as 
epinephrine and similar drugs. The vasocon- 
strictors are added to retard absorption, which 
in turn decreases s\'stemic toxicity and pro- 
longs the effect. 

Local anesthetics are basic organic substances 
which form salts with mineral and organic 
acids. The majority of injectable drugs are 
esters. The salts are soluble in water and in- 
soluble in organic solvents. The bases are solu- 
ble in organic solvents, oils and vehicles used 
for ointments, but poorly soluble in water. 
Alkalis precipitate the basic form from aqueous 
solutions of salts. 

Detoxification of local anesthetics occurs in 
the liver. The rate varies with the chemical 
nature of the drug. Some are completely hydro- 
lyzed and the by-products are excreted into the 
urine. Procaine, for example, is converted to 
para-aminobenzoic acid and diethylaminoeth- 
anol. Others are partly detoxified and partly 
eliminated unchanged in the urine (cocaine). 
Still others are almost entirely eliminated un- 
changed. Greater toxicity is usually associated 
with slowly eliminated or detoxified drugs. 

The effective concentration of a local anes- 
thetic depends upon the size of the nerve fiber. 
Autonomic and sensory fibers of a mixed nerve 
are smaller than the motor fibers. If a 'nerve 
containing all three components is exposed to 
a dilute solution of a local anesthetic, a block- 
ade of the sensory and autonomic fibers devel- 
ops first. Conduction remains in motor com- 
ponents for a variable period. Later, the motor 
components are effected. This apparent selec- 
tivity depends upon the ease of penetration of 
the drug into the fibers. Drugs penetrate non- 
myelinated fibers more easily than myelinated. 
Penetration into the large nerve trunks, since 
they have a denser perineural sheath than do 
the small, occurs at a slower rate. More con- 
centrated solutions are necessary for successful 
blockade of larger, centrally located nerve 
trunks than of tbe smaller, peripherally located 
branches. The nerve endings in the skin and 
subcutaneous areas are anesthetized with still 
more dilute solutions. 

When nerve trunks are large, fifteen to 
twenty minutes may elapse before a satisfactory 
block is established. This lapse in time, from 
the moment of injection until the blockade is 


established, is the sum of the time required for 
the drug to diffuse through the soft tissues, the 
time to penetrate and diffuse through the neu- 
ral sheaths, and the time required to diffuse 
through the perineural nerve membrane and 
into the ner\'e fiber. 1 he ease of penetration of 
a drug through the membrane of a nerve fiber 
is a ph\'sical factor which varies with the con- 
figuration of the molecule of the drug. This 
latent period, during which nothing seems to 
be happening, is greater for the longer lasting 
drugs. Presumably, the longer lasting drug dif- 
fuses slowly through the membrane. The out- 
ward diffusion when the concentration of drug 
in the medium surrounding the nerve fiber is 
reduced below the equilibrium level, also is 
slow. These are the reasons for the differences 
in onset and duration of action of various drugs. 

Procaine is the best known and the safest of 
the local anesthetics. It is almost universally the 
agent of choice for local and regional anesthesia. 
It is rapidly detoxified and eliminated. Re- 
actions are mild when they occur and local 
damage to tissues is uncommon. The conven- 
tional concentrations and volumes for average 
adults are as follows: 

2 per cent — not more than 50 cc. in one hour (1 gm.) 

1 per cent — not more than 100 cc. in one hour (1 gm.) 
0.5 per cent — not more than 200 cc. in one hour 

As a general rule, not more than 1 gm. should 
be used at any one sitting. Procaine possesses 
no topical action and cannot be used to anesthe- 
tize mucous membranes. The duration of action 
of procaine in a nerve block averages forty-fi^'e 
minutes. 

Besides the chemical nature of a drug, dura- 
tion of action is influenced also by the site of 
injection, blood supply in the area injected, 
concentration, and ability to detoxify the drug. 
In the scalp, where the blood supply is excel- 
lent, duration is almost half that of the back 
where it is less abundant. 

Tetracaine (Pontocaine) is more potent and 
more toxic than procaine. It is second in impor- 
tance to procaine for surgical anesthesia. One 
milligram of tetracaine is equivalent to 10 mg. 
of procaine as regards its anesthetic potency. 
The duration of action of tetracaine is almost 
twice that of procaine. It is possible, if epineph- 
rine is added to solutions of tetracaine, to obtain 
a block lasting from two to four hours. Large 
nerve trunks are blocked with 0.15 per cent 
solutions, smaller trunks with 0.10 per cent, 
and nerve endings (infiltration) by 0.05 per 



1 7 6 Chapter 7 . 

cent to 0.075 per cent solutions. Tetracaine is 
used extcnsiv^eiy for spinal anesthesia. 

Symptoms of toxicity following the use 
of tetracaine are more frequent and serious 
than those of procaine. Reactions are character- 
ized by syncope and circulatory collapse. As a 
rule, few if any prodromal symptoms precede 
or forewarn of impending catastrophe. The use 
of tetracaine for other than spinal block should 
be reserved for those experienced in the tech- 
nique of regional anesthesia. 

Piperocaine (Metycaine) is closely allied to 
cocaine chemically, being an ester of benzoic 
acid. It is similar to procaine in most respects. 
However, it is somewhat more potent and 
longer lasting. One and one-half per cent solu- 
tions are suitable for blocking large and me- 
dium sized nerve trunks. A one per cent solu- 
tion should be used for smaller nerve trunks 
and for infiltration. 

Lidocaine is a newer anesthetic drug. It is a 
xylidide (not an ester), but it does possess the 
general chemical configuration common to 
other local anesthetics. It has a very brief latent 
period and produces almost immediate anes- 
thesia and, when infiltrated, it produces an 
effect lasting one hour without epinephrine 
and two to three hours with epinephrine. 
The volumes and strength of solutions recom- 
mended are approximately one-half to two- 
thirds of those for procaine in similar situa- 
tions, Lidocaine possesses striking ability to 
diffuse through tissues. Thus, if perchance the 
needle is introduced some distance from the 
nerve, an effective block is still obtained be- 
cause the drug diffuses , over a wide area and 
reaches the nerve. The incidence of failures is 
reduced noticeably in comparison to procaine 
when one adopts the drug. Blocks in which 
motor effects are partial or absent when pro- 
caine is used, yield complete flaccidity with 
lidocaine. 

Dihucaine (Nupercaine) is approximately 
fifteen times more potent and toxic than is 
procaine. Its effect -is longer lasting than that 
of any of the currently used drugs. Nerve 
blocks may be performed with a 0.075 per cent 
solution and infiltration with a 0.05 per cent. 
Sloughs and severe systemic manifestations of 
toxicity have been reported. The drug is not 
recommended for infiltration and nerve block- 
ing hut is suitable for spinal anesthesia. 

Commercially prepared, ready mixed and 
sterilized solutions of local anesthetic drugs are 
available in sealed glass ampules or multiple- 


Anesthesiology 

dose vials. Such preparations are preferred, from 
the standpoint of safety, stability, asepsis and 
ease of handling, by the operator to those made 
up from tablets and powders. Accidents due to 
the use of concentrated solutions and the pos- 
sibility of contamination are thus avoided. 

When these preparations are not available, 
the powder may be dissolved in the appr()])riate 
solvent and sterilized by autoclaving or boiling. 
Epinephrine is added at the time the solution 
is used because it is not stable and cannot be 
boiled. Solutions as nearly isotonic as possible 
are used in order to prevent swelling and 
edema of the tissues during operation and local 
irritation afterwards. Potent drugs such as tetra- 
caine or dihucaine are dissolved directly in 
physiologic saline, since the amount necessary 
for effectiveness is, comparatively speaking, 
minute and toxicity is not altered. Tw'o per cent 
procaine must be prepared with 0.45 per cent 
sodium chloride to be isotonic. 

The most efficient vasoconstrictor for local 
anesthesia is epinephrine. It is nev'cr used for 
patients with cardiovascular disease, peripheral 
vascular disease, hyperthyroidism or those who 
have had a sympathectomy. Injections of solu- 
tions containing epinephrine into the lingers 
and toes, particularly when peripheral vascular 
disease is present, may cause gangrene and 
slough. 

REACTIONS TO LOCAL ANESTHETIC DRUGS 

When a local anesthetic drug gains access to 
the blood stream, either by injection or by 
absorption, a train of symptoms commonly re- 
ferred to as a 'reaction’^ results. Two types of 
reactions are recognized: the depressant or car- 
diovascular type and the stimulating or con- 
vulsive type. 

The depressant type of reaction is due to 
circulatory collapse, which is the result of de- 
pression of the myocardium, dilatation of the 
vascular bed, or a combination of both. The 
onset is usually abrupt, sometimes after the use 
of a minute amount of the drug. Sudden pallor 
appears followed by syncope and respiratory 
failure and death. In mild reactions the onset is 
slower, and circulatory failure supervenes 
gradually. The patient becomes drowsy and 
passes into a coma-like state. Manifestations 
such as thpe have been ascribed to ^idiosyn- 
crasy, or sensitivity.’’ It is generally conceded 
that they are due to overdosage when precau- 
tions outlined for using local anesthetics have 
not been observed. Artificial respiration must 



177 


Spinal Anesthesia 


be instituted if respiratory failure has occurred. 
If asystole is suspected, both cardiac massage 
and artificial respiration must be instituted 
simultaneously without delay. 

The central nervous stimulation type of re- 
action is ushered in by apprehension, excite- 
ment, disorientation and is then followed by 
convulsions and other manifestations of intense 
central nervous stimulation. The circulatory 
type of reactions occurs less frequently than 
does the central nervous system type. Pallor, 
yawning, nausea and vomiting may precede the 
convulsions. The prodromal signs of the nerv- 
ous system type are often dismissed as hysteria. 
The severity and duration of the stimulation 
depend upon the pharmacologic nature and 
rapidity of absorption of the drug. The convul- 
sive manifestations may be fleeting and be fol- 
lowed by a paralytic phase if large amounts of 
the drug are absorbed or injected. The subject 
is then comatose, completely depressed and in a 
state of circulatory collapse. 

The convulsions are controlled by the intra- 
venous administration of an ultra-short acting 
barbiturate (thiopental or hexobarbital). If 
neither of these is available, one of the short 
acting barbiturates such as secobarbital or 
pentobarbital may be used. The barbiturate is 
given intravenously in a quantity sufficient to 
control the convulsions. The ultra-short acting 
barbiturates are more suitable for this purpose 
because they act quickly and are more potent. 
Barbiturates merely antagonize the stimulating 
action. They do not hasten detoxification or 
elimination of local anesthetics, they do not 
overcome the depressant affect on the circula- 
tory system and they do not antagonize the 
paralytic phase of a reaction. They are suitable 
only to control convulsions. 

Regional anesthesia should not be attempted 
without having available an ultra-short acting 
barbiturate, a vasopressor drug, a syringe and 
needle and some effective method of adminis- 
tering artificial respiration. The pallor, tachy- 
cardia, tremor and excitement caused by epi- 
nephrine used with the local anesthetic drug 
may easily be confused with the prodromal 
phase of a reaction. However, disorientation, 
convulsions and coma are uncommon symp- 
toms. 

The use of the intradermal wheal to deter- 
mine sensitivity to local anesthetic drugs is a 
traditional procedure of doubtful value. Pa- 
tients presenting a history of developing loss of 
consciousness or coma, following the injection 


of small quantities of local anesthetic drugs, 
should be regarded with suspicion and studied 
further before a block is attempted. 

SPINAL ANESTHESIA 

In spinal anesthesia thi^anjerio r and posterior 
roots of the spinal nerves are blocked as they 
arise from the spinal cord. The neurons and 
tracts on the surface may be involved, but the 
descending and ascending tracts deep in the 
cord substance are not blocked. The extent of 
the block, referred to as height or level, depends 
upon the number of spinal roots bathed by the 
solution. The perineal or saddle area is anesthe- 
tized when the sacral segments only are in- 
volved. The block is often called saddle block. 
The lower extremities are anesthetized when 
both the sacral and lower lumbar segments are 
involved. The block is referred to as loiv spinal 
Mock. When the sacral, lumbar and fowler 
thoracic segments are blocked, the block is re- 
ferred to as medmn, or simply a blo ck. 

If the drug is forced into the upperTKofacic 
area, the block is called a hig h spinal block . 

The spinal cord, in mosFadults, ends be- 
tween the second „and third lumbar vertebrae. 
Lumbar puncture is always performed below 
this site to avoid trauma to the cord. The drug 
used determines the duration of spinal anes- 
thesia; varying the dosage does not. The extent 
or level is controlled by dosage, specific gravity 
of solutions, positioning and rate of injection. 
The height or level of anesthesia is controlled 
by using solutions which are heavier or lighter 
than spinal fluid. Solutions heavier than spinal 
fluid are referred to as hyperbaric; lighter solu- 
tions as hypoharic; those of the same specific 
gravity as isobaric. 

The effects of gravity are utilized in directing 
the drug to the desired segments. In the head- 
down, supine position a hypoharic solution 
migrates caudad, a hyperbaric one gravitates 
cephalad. In the head-up position the reverse is 
true. Blocks induced with procaine, int racain e 
and i riperocaine last approximately oneTiourT 
vrith fetracaine and hexylcaine two hours, and 
with di bucain e three hours f Epinephrine added 
to the solution increases the duration approxi- 
mately 60 per cent. Long-lasting anesthesia is 
obtained by using dibucaine or tetracaine com- 
bined with epinephrine by the single injection 
method or by the continuous spinal technique. 
In the latter technique, a catheter of small bore 
is introduced intrathecally and the drug is 
injected at intervals as often as necessary. 



178 Chapter 7 . Anesthesiology 


Spinal anesthesia provide s niusclc relaxation 
superior to other methods oF anesthesia. Sur- 
geons prefer spinal anesthesia for the relaxa- 
tion it affords. 

Certain physiologic disturbances occur dur- 
ing spinal anesthesia of far-reaching impor- 
tance. In high spinal anesthesia, a blockade of 
sensory and motor hbers occurs in the sacral, 
lumbar and lower thoracic segments. However, 
the autonomic fibers are not all blocked. The 
sympathetic and parasympathetic fibers in the 
lower spinal segments are inactivated. In the 
thoracic segments, the majority of the sympa- 
thetic fibers are blocked but the parasympa- 
thetic fibers, since they arise in the cranial 
nerves, remain intact. This partial denervation 
of the autonomic nervous system in the upper 
part of the body causes hypotension, brady- 
cardia, nausea, vomiting, contraction of the 
bowel and other changes. 

Some of the advantages of spinal anesthesia 
are that it provides excellent muscle relaxation. 
The reflex arc is interrupted and muscles are 
completely paralyzed. The block is accompanied 
by little or no disturbances of metabolic proc- 
esses, if there is no hypotension. Loss of con- 
sciousness, excessive secretions, excitement, 
ppstanesthetic nausea, somnolence and other 
disagreeable features of general anesthesia are 
avoided. Cautery or electrical equipment may 
be used without fear of explosions. The opera- 
tor may administer the anesthetic himself. 

One disadvantage of spinal anesthesia is that 
it is noncontrollable. Once anesthesia has been 
instituted, it cannot be terminated. Its duration, 
although predictable, is usually uncertain. The 
operation may outlast anesthesia and supple- 
mentary general anesthesia is required which 
subjects the patient to the hazards of two 
anesthetics. Failures, due . to technical errors, 
cannot be wholly excluded even in most skilled 
hands. The r notor paralysis at high lev els causes 
respiratory depression from, the -resulting, inter- 
costal and diap hragmatic pa resis. Hyp otension 
is common. Paralysis of the m-useles and the 
autonomic denervation contribute to the periph- 
eral circulatory failure. Vasopressor drugs are 
usually effective in overcoming circulatory fail- 
ure in healthy subjects, but those with a dis- 
eased vascular system do not always respond. 
Postoperative neurologic complications, though 
infrequent, are a possibility. The effects of the 
drug on the nervous tissue, trauma from the 
needle, infections, and the use of contaminated 
ox deteriorated solutions may be causative fac- 


tors. One objection which is often offered is 
that the patient remains conscious throughout 
the operation. All patients are not cooperative 
and, therefore, arc not psychically suited for 
spinal anesthesia. The vagal pathways from the 
viscera are not blocked during the lime of 
operation causing impulses to pass to the 
medulla. This may initiate \'cxs()mc retching, 
nausea, and vomiting particularly when trac- 
tion is made on the viscera. Iiupujses pass along 
t he syanpa the ti c_ch ain j ir ,„a..xctrogiad.w, m a n n c r 
and thence into the cord above the le\'cl (if the 
block. The patient experiences [rain in the 
thorax when traction is made upon the viscera. 

Because circulatory dejuTssion is a promi- 
nent and common disturbance in spinal anes- 
thesia, this technique is usually contraindicated 
when cardiovascular diseases are present. 
Severe hypertension, disturbances in cardiac 
rhythm, myocardial disease, and cardiac failure 
are contraindications to spinal anesthesia. 
Hypotension, and hypovolemia from any cause 
are contraindications to spinal anesthesia for 
the obvious reason that the vascular bed is in- 
creased in size and circulatory depression re- 
sults. Neurologic diseases, whether degenera- 
tive or suppurative, arc contraindications to 
this method of anesthesia. Although no evi- 
dence exists that these diseases arc aggravated 
by spinal anesthesia, one must rememher that 
patients, at a later date, may ascribe symptoms 
of the disease to the spinal anesthetic and 
create a medicolegal problem. Spinal anesthesia 
should not be used when diseases of the respi- 
ratory system accompanied by severe pulmonary 
insufficiency are present. Intercostal paralysis 
accompanies high spinal anesthesia, decreases 
tidal exchange and. causes a reduction in vital 
capacity. Anemia is a contraindication to spinal 
anesthesia because the oxygen carrying power 
of the blood is reduced and tissue anoxia may 
occur. Diseas.es characterized by increased intra- 
abdorninal pressure due to distention from gas, 
ascites, .or. large tumors are contraindications to 
spinal anesthesia because a severe irreversible 
fall in blood pressure may follow induction of 
the block in these subjects. Septicemia also is a 
contraindication because the organisms may be 
carried into the spinal canal by the needle. 
Spinal^esthesia should not be used for opera- 
tions above the Sapiragm. Infections about the 
vertebral column at the site of lumbar punc- 
ture are contraindications for the same reason. 
Psychically disturbed subjects are not good 
.candidates for spinal anesthesia. Patients of acb 



Epidural Anesthesia 


\ cinccd age usually develop cii‘culatur\ dis- 
turbances more frequentk- than younger sub- 
jects because the \’asomotor compensatorv 
mechanisms are not as effecti\’e. Children like- 
wise are not good subjects for spinal anesthesia 
because they are psychically unsuited. Distor- 
tions and bony changes in the \’ertebral column 
often preclude the use of spinal anesthesia be- 
cause lumbar puncture is difficult to perform. 

Neurologic jcomplications may follow spinal 
anesthesia postoperatively. The" most t’exsome 
and annoying of these is postlumbar puncture 
headache, which is believed to be due to the 
leakage of spinal fluid from the perforation 
made by the needle in the dura. It is transient 
and lea\^es no sequelae, fortunately. Of more 
serious consequence are the neurologic symp- 
toms wffiich appear after spinal anesthesia. The 
least common and most serious of these is para- 
plegia, the exact cause of wffiich is not known. 
Myelitis and arachnoiditis have been found in 
subsequent examinations after this s\ndrome 
has appeared. Pre-existing neurologic diseases 
and errors in technique are belie\’ed to play a 
role. Ealsies o£, the cranial nerves, particularly 
the Sjxth^Jso appear afteF spinal anesthesia on 
rare occasions. These are related to the loss of 
cerebrospinal fluid and are associated with 
headache. Infection from contamination results 
in meningitis, arachnoiditis or abscess. Back- 
ache follows lumbar puncture at times. This 
may be due to trauma to the periosteum, the 
ligaments, or to the intervertebral disk or to the 
aggravation of pre-existing skeletal muscular 
disorders. 

EPIDURAL ANESTHESIA 

In epidural, or peridural, anesthesia the spinal 
nerves are blocked as they pass through the 
epidural space. A needle is introduced at the 
lumbar area in the same manner as it is for 
lumbar puncture as far as the dura. Neither 
the dura nor the arachnoid is pierced. A modi- 
fied form of epidural anesthesia is obtained by 
introducing a needle through the sacrococc}:^- 
geal membrane into the caudal canal and in- 
jecting a large volume of a local anesthetic 
solution at this site. This is referred to as caudal 
or sacral anesthesia. 

Epidural block is more difficult, hazardous 
and cumbersome to induce than caudal block, 
or spinal block, because the needle may inad- 
vertently be introduced into the subarachnoid 
space and a lethal amount of solution deposited 
there. The spinal nerves acquire a sheath as 


179 

the\ pass through the epidural space. More 
concentrated and larger \ulumes of solution are 
necessary for penetration than are used for 
spinal anesthesia. Epidural anesthesia is used 
for the same purposes as spinal anesthesia. The 
indications for lumbar peridural block arc few. 
The caudal technique, wfliich is safer and is 
more easily performed, is used for rectal and 
other perineal operations. The possibility of 
headache, meningitis, encephalitis or other 
neurologic complications is less compared to 
spinal anesthesia. The drug migrates from the 
epidural space through the inteiwertebral fora- 
men along the spinal nerves. Some evidence 
exists that it diffuses into the subarachnoid 
space. The drug does not contact the naked 
nerve roots, or the cord, as in spinal anesthesia. 

Ihe disadvantages of peridural block are that 
the needle ma\' be placed in the subarachnoid 
space instead of the epidural and an overdose 
of local anesthetic drug deposited there. Muscle 
relaxation is not always adequate. The level of 
analgesia is unpredictable and difficult to con- 
trol. Drug reactions may occur because large 
amounts are needed for effective blocking. The 
drug does not always easily penetrate each of 
the spinal ner\'es and anesthesia is incomplete 
or segmental. The possibility of intra\^ascular 
injection exists because the epidural space is 
lined with a plexus of veins. 

INFILTRATION ANESTHESIA 

As the rule, most minor surgical procedures 
may be performed after infiltration of the opera- 
tive site with the desired local anesthetic drug. 
Procaine (1 per cent) is the most widely used 
agent for this purpose. 

NERVE AND FIELD BLOCKS 

Direct nerve blocking is adopted wffien the 
operative site is in an area supplied by easily 
accessible nerves. In some areas, as for exam- 
ple, the upper thorax, overlapping of nerves 
occurs so that blocking would have to be exten- 
sive. The anesthetic procedure might be of a 
greater magnitude than the operation itself. 
Nerve blocks, thus, are more practical for 
operations in the extremities or about the head 
than for those on the thorax and trunk. A field 
block may be considered as intermediate be- 
tween a nerve block and infiltration. The 
anesthetic is deposited at the point of division 
of a nerve into branches so that the area distal 
to this point is anesthetized. Infiltration along 
the costal margin from the xiphoid to tenth rib 



180 


Chapter 7 . 

blocks the branches of the lower intercostals to 
produce an abdominal field block. Anesthesia 
of the lower abdominal area is obtained by 
extending the line of infiltration along the 
outer border of the rectus muscle. 

Brachial plexus block is widely used for 
anesthesia of the arm and forearm. The trunks, 
divisions or cords of the plexus are infiltrated 
with a local anesthetic solution above the clavi- 
cle or in the axilla. In the supraclavicular ap- 
proach, the nerves are blocked by depositing 
the solution along the first rib. Pneumothorax 
and trauma to the great vessels are possibilities. 
In the axillary route, the injection is made in 
the medial aspect at the midline at the level of 
insertion of the pectoialis major. The median 
nerve is also blocked at the elbow or the wrist. 
When block is attempted at the elbow, the 
landmarks are the brachial artery and the ten- 
don of the biceps at the antecubital fossa. The 
radial nerve is also blocked at the elbow and 
wrist. When block at the elbow is attempted, 
an intradermal wheal is raised lateral to the 
biceps tendon and the needle introduced per- 
pendicular to the skin and advanced until the 
lateral condyle of the humerus is encountered. 
The ulnar nerve is blocked at the elbow or 
wrist also. The landmarks for block at the 
elbow are the groove of the internal condyle of 
the humerus and the olecranon process. By 
combining a block of these three nerves at the 
elbow, anesthesia of the forearm and hand may 
be obtained. At the wrist, the needle is intro- 
duced between the tendons of the palmaris 
longus and flexor carpi radialis muscles at the 
level of the ulnar styloid to block the median 
nerve. The ulnar nerve likewise may be blocked 
in the same area by introducing a needle on the 
radial side of the tendon of flexor carpi ulnaris 
muscle at the level of the ulnar styloid. The 
radial nerve may he anesthetized at the wrist 
in the anatomic snuffbox. 

The digital nerves are blocked on the lateral 
and medial aspects of the digits at the proximal 
phalanges. Gangrene may result from ischemia 
due to the injection of large volumes of solu- 
tion. Brachial plexus block or blocks at the 
elbow or wrist are preferred. 

The intercostal nerves are blocked as they 
course the intercostal spaces at a point in the 
midaxillary line on the inferior border of the 
rib. The femoral nerve is blocked below Pou- 
parts ligament lateral to the femoral artery. 
Used alone, it is satisfactory for operations on 
the anteromedial aspect of the leg. Combined 


Anesthesiology 

with sciatic nerve block, it is satisfactory for 
operations below the knee, dlie sciatic nerve is 
blocked 3 cm. inferior to the miebpoint of a line 
drawn between the iliotroclianteric crest and 
the postcrosuperior iliac spine. I he anterior 
and posterior tibial nerves are blocked at the 
ankle to perform operations on the loot. The 
spinal nerves arc blocked as they emerge from 
the intra vertebral foramina along the bodies of 
the vertebrae by the technique known as para- 
vertebral block. In the cervical area, block of 
the spinal nerves is referred to as cer\'ical plexus 
blocks; in the thoracic area, as thoracic para- 
vertebral block; and the lumbar area, as lumbar 
paravertebral block. Transacral block, also a 
paravertebral block, is perldnned by passing 
needles into the sacral Foramina through the 
dorsal aspect of the sacrum. 

REFRIGERATION ANi:S1HESIA 

At a temperature of 4° C. nerv^e conduc- 
tion is retarded. An extremity which is de- 
vitalized and requires ablation may be packed 
in ice for several hours and quickly amputated 
while still cold. The anesthesia rarely lasts 
more than thirty minutes. A tournicfuet may 
be applied and the limb packed with ice for 
many hours until conditions for oficration are 
more favorable in serious cases. This is tanta- 
mount to a physiologic amputation, 

INTENTIONAL HYPOTENSION DURING 
OPERATION 

A sympathectomized subject withstands 
blood pressures at shock levels induced by 
hemorrhage for longer periods of time than 
does one whose vasomotor control is intact. 
This principle is applied to minimize blood loss 
by reducing oozing in surgical procedures in 
which hemorrhage is anticipated. The denerva- 
tion is accomplished either by using (1) a high 
spinal block, (2) a ganglionic blocking drug, 
(3) a sympatholytic drug or by (4) performing 
arteriotomy. When arteriotomy is performed, 
the blood is collected in a sterile receptacle 
containing an anticoagulant and retransfused. 
The vasomotor control remains and the advan- 
tages of sympathectomy are not obtained. The 
practical methods employ ganglionic blocking 
drugs such as hexamethonium or Arfonad. 
Thrombosis of the cerebral, coronary, mesen- 
teric and other vessels may occur. Cerebal 
damage from local tissue anoxia, anuria, and re- 
actionary hemorrhage are other sequelae and 
complications. The method is reserved for ex- 



181 


Intentional Hypothermia During Operation 


ceptional situations and is one which is not 
used routinely. 

INTENTIONAL HYPOTHERMIA DURING 
OPERATION 

Cooling the tissues reduces metabolic activity 
of cells. When a central nen'ous system depres- 
sant is administered, the heat-regulating center 
is depressed and the body temperature tends 
to approach that of the external environment. 
Certain operations, such as cardiac operations 
designed to relietx cyanosis due to congenital 
defects, or vascular operations in wdiich the cir- 
culation to an organ is interrupted for a |x;riod, 
are facilitated and made possible by the reduc- 
tion in metabolic activity of the cells. The 
period of ischemia can be increased without 
causing undue harm. The patient is anes- 
thetized with a volatile, or nonvolatile, drug 
and immersed in ice water or wrapped in spe- 
cial blankets through which ice water cir- 
culates. The body temperature is reduced to a 
temperature between 28 and 24"^ C. The pro- 
cedure is not without hazard. Ventricular fibril- 
lation readily occurs at low temperatures. 

OPERATING ROOM DEATHS 

Most fatalities in the operating room in 
wTich anesthesia is the primary cause are due 
to: (1) asphyxia or inadequate ventilation, (2) 
overdosage of the anesthetic drug, (3) a com- 
bination of overdosage and asphyxia, (4) un- 
toward reactions to drugs, or (5) sudden, se- 
vere, neurogenic shock. 

Often fatalities ascribed to anesthesia are 
found, after careful postmortem examination, 
to be due to causes not related to anesthesia, 
Emboli caused by clots, air or fat head the list. 
Sudden cardiac failure due to coronary artery 
disease or other cardiac ailments is the most 
common cause. Severe untreated or irreversible 
shock causes death during operation but rarely 
is death sudden and unexpected. Cerebral 
vascular accidents are uncommon, but do occur. 
Anoxia, carbon dioxide excess, excitement due 
to inadequate preparation, and the use of 
vasopressor drugs may precipitate cerebral hem- 
orrhage. Death, however, occurs after opera- 
tion and seldom is it sudden. Uncontrollable 
massive hemorrhage from technical errors may 
account for some operating room fatalities. Ad- 
renal insufficiency is a rare but possible cause of 
sudden death during operation. 

In the absence of postmortem examinations, 
operating room fatalities are often ascribed to 


obscure, highly spcculati\'e causes. The myth- 
ical status hmphaticus has in the past provided 
an explanation for technical anesthetic errors. 
This s\ndronie is no longer accepted as a 
clinical entity. Vago-vagal reflex is another 
overemphasized and convenient alibi for tech- 
nical errors of anesthesia. Controvers\ exists 
concerning this reflex. Its occurrence, how'- 
ever, is not denied, but how frequently it 
causes death is debatable. Available evidence 
indicates that vago-vagal reflexes do not cause 
death except when complicated by anoxia. 
When oxygenation is adequate and no disturb- 
ance of acid-base balance exists, sudden death 
does not occur irrespective of the intensity of 
the vagal stimulation. 

Fatalities due to asphyxia during general 
anesthesia result from: (Ij reduction of the 
oxygen tension of the inhaled mixture, (2) 
obstruction to respiration from relaxed tissues, 
secretions, blood or \'omitus, or (3) inadequate 
tidal exchange from hypoventilation. Death 
is usually due to anoxia. Hypoventilation often 
results in respiratory acidosis which may be 
the causati\’e factor rather than the suboxygena- 
tion. Deaths due to overdosage are actually 
asphyxial deaths because, under these circum- 
stances, parah’sis in the respiratory centers 
causes apnea. 

Obstruction of the respirator}^ passages ac- 
counts for the majority of asph}’xial deaths. 
Aspiration of vomitus and other material ac- 
counts for many cases of obstruction. The 
patient with a full stomach is a poor risk from 
an anesthetic standpoint. Irrespective of the 
type of anesthesia administered, whether it he 
local, intravenous, inhalation or spinal, the pa- 
tient wTo has recently partaken of food or drink 
vomits during or after operation. Solid particles 
from the stomach are drawn into the trachea 
and bronchi and cause obstruction. The supine 
position, irrespective of the activity of the cough 
reflex, favors aspiration if vomiting occurs. Op- 
erations should be p<jstponed if the patient has 
recently partaken nl (nod or drink. Gastric 
lavage and cmelies eax of- little value in com- 
pletely cmptN'ing d^e sioiiiach. Excess secretion 
of mucus rcsiilL* pu-mcclication with an 

anticholinvrg‘'< doio' Obstruction 

may occur ii du aneNtlu‘tK| unable to main- 
tain a proper aiiwax patient is in 

the lateral <h pioia or because the 

tissues io passages are re- 
laxed 05 i,’ * anesthesia ob- 
viates f * I' . 'd'rance to nonvola- 



182 Chapter 7. Anesthesiology 

tile drugs such as barbiturates causes some fa- Food is withheld after the ci^ening meal, 

talities. The use of a combination of a non- Proper preopera ti\x' medication is iraportant 

volatile drug, a relaxing agent and an inhala- to allay apprehension and to obtain psychic 

tioii anesthetic multiplies the hazard of each sedation. A patient who is extremely appre- 

dmg. hensivc is dillicult to anesthetize with an in- 

Most fatalities occur during induction or at halation anesthetic. When nitrous oxide is 

the conclusion of anesthesia, less frequently used, the task is almost impossible, 

during maintenance. Nonchalance on the part ^ Premedication is also necessary to obtain an 
of the anesthetist and carelessness or though tJ^ticlditivc effect in order to fortil'v a clruu of low 


lessness may be underlying factors. In patients 
whose airways become easily obstructed, ob- 
struction takes place early and the patient is 
asphyxiated at this time. Vomiting occurs dur- 
ing light anesthesia. This happens most often 
during induction or at the conclusion of the 
procedure. Irrespective of the drug and method 
of administration, as long as there is loss of 
consciousness, danger from asphyxia exists. 

Deaths from spinal anesthesia are caused 
by respiratory paralysis or circulatory failure. 
Respiratory paralysis results if the drug is 
forced or diffuses into the upper thoracic and 
cervical portion of the spinal canal and causes 
paralysis of the intercostal muscles in the 
diaphragm. If immediately recognized and arti- 
ficial respiration is commenced promptly, the 
complication is not serious. Peripheral circula- 
tory collapse during spinal anesthesia is due to 
failure of neurogenic control of the vascular sys- 
tem. It is readily overcome by vasopressor drugs 
(ephedrine, desoxyephedrine or Neosyne- 
phrine). When it occurs suddenly, as it does 
in poor-risk subjects, and cannot be promptly 
corrected, or if it is disregarded, cardiac arrest 
results. Pre-existing cardiovascular disease in- 
creases the hazard of spinal anesthesia. 

?REPARATION OF PATIENT FOR 
ANESTHESIA 

The proper preparation of the patient for 
anesthesia is important. The patient is hos- 
pitalized, at the latest, the evening prior to op- 
eration. Preoperative examination consists of 
^^^d ng a history, and performing a general phys- 
icaFexamination with special attention to the 
cat^iQvasQjdar.an respir atory systems . A urine 
exaltation rules out or confirms the presence 
t^iabejes or renal j isease. He moglobin^ de- 
termmations are miportanf becausFt]§o?^en- 
carrying power of the blood is of especial inter- 
est to the anesthetist. Patients with anemia do 
not tolerate even mild disturbances in ventila- 
tion. A barbiturate of the short acting type or 
other hypnotic drug is administered at bed time 
to assure adequate rest and allay apprehension. 


'Tdtenc^An^l^)lii^^ arc ncccssaiy to 

minimize secr etions. Prcmcdication may also 
be administered prophylaclically to overcome 
undesirable side effects caused by anesthetic 
drugs, such as vagal stimulation, hypotension 
and cardiac arrhythmias. 

The narcotics are the most siiita!)lo drugs 
for psychicsccIatTon. They arc supmaor to the 
barhituraTeirM^ is still the most suitable 
of the narcotics. Dilaudid, mcthaclon, or meperi- 
dine is used for patients who cannot tolerate 
opium derivatives. Methadon and meperidine 
are satisfactory as analgesics but pos.scss less 
hypnotic activity than docs morphine and are, 
therefore, not as effective. 

The time and route of administration is im- 
portant. The o])timum effects are atltiinecl when 
the narcotic is administered suhcutancously 
one to one and one-half hours prior to the an- 
ticipated time of the induction of anesthesia. In 
urgent situations, the o])timum effects arc ob- 
tained within five minutes if the drug is ad- 
ministered intravenously at a slow rate. The 
narcotics are combined with belladonna alb- 
loids— atropine, hyoscyamine or scopolaminc- 
which are anticholinergic substances, lliey 
are used to minimize the secretion of mucus 
and saliva, bcop olaminc and hyoscyamine are 
more effective than atropine. Scbprffamiiie de- 
presses the cerebral cortex and enhances the 
effects of morphine. The sedation is accom- 
panied by amnesia and an air of indifference 
which facilitates operation and obviates psychic 
trauma. Atropine and hyoscyamine stimulate 
the cortex and antagonize the sedative action 
of morphine. The belladonna alkaloids are ad- 
ministered simultaneously, even by the in- 
travenous route. The average acliilt dose is 
grain (15 mg.) morphine' with Yujo grain 
of belladonna alkaloid. For patients beyond thz 
fourth decade of life the morphine is reduced 
Vi> grain (10 mg,). Patients in the sixth 
and seventh decades tolerate less-j/s to % 
grain (7.5 to 10 mg,). Those who arc older 
require still less-^-^o to grain (5 to 7,5 mg.). 
The belladonna alkaloid is reduced correspond- 



Precautions 


183 


ingly in a ratio of 1 part to 25 parts of morphine. 
Morphine is omitted if basal narcosis with an 
intravenous or a rectalh' administered drug is 
contemplated. In infants and children, ultra- 
short acting barbiturates ma} be administered 
rectally for basal narcosis f 1 gm. for each 50 
lbs. of body weight) one-half hour prior to in- 
duction of anesthesia. Preancsthetic sedation 
is desirable but is usually omitted if the patient 
is to be ambulatory immediately after opera- 
tion. Ambulation after the administration of 
narcotics and hypnotics or general anesthesia 
is undesirable. Ataxia, drowsiness, nausea and 
vomiting are common in ambulatory patients 
after narcotics are administered. If the patient 
is hospitalized, as he should be for most sur- 
gical procedures, morphine and scopolamine in 
the usual doses are employed. Barbiturates are 
recommended prior to regional anesthesia to 
allay apprehension and to minimize or avoid 
convulsions due to local anesthetic drugs. Bar- 
biturates completely antagonize or prevent 
stimulation by an overdose of a local anesthetic 
drug in basal narcotic doses only. Secobarbital 
or pentobarbital grains, 100 mg.) orally, 
or intramuscularly, one and one-half hours 
prior to operation allays but does not prevent 
excitement and convulsions. All efforts should 
be made to perform the operation under cir- 
cumstances which permit the use of premedica- 
tion. Many a successful regional anesthetic pro- 
cedure has been classed as unsatisfactory be- 
cause the patient was apprehensive. 

PRECAUTIONS 

There are certain generalizations which are 
applicable to all forms of anesthesia but more 
particularly to general anesthesia. 

1. No general anesthetic, no matter how 
brief in duration is the anesthesia or how light 
the plane, should be administered in situations 
in which there are no provisions for immedi- 
ately instituting artificial respiration. The ap- 
paratus employed for inhalation anesthesia is 
used to administer artificial respiration by the 
intermittent insufflation technique. This 
method is wholly adequate for resuscitation 
under circumstances encountered during sur- 
gical anesthesia. Unless an unimpeded airway is 
established, no method of artificial respiration 
is successful. Airways of the pharyngeal type 
are satisfactory for relieving supralaryngeal ob- 
struction. Contrary to certain teachings, endo- 
tracheal intubation is not always necessary for 
resuscitation. Valuable time is often wasted in 


attempting to introduce an endotracheal cathe- 
ter befcu’e artificial respiration is instituted. In- 
tubation is indicated onl} when the usual meas- 
ures for establishing an airwa} fail. 

2. A suction apparatus for the cxclusii'C use 
of the anesthetist should be in each operating 
room. A curved metal suction tip which per- 
mits cleansing secretions from the h\’popharynx 
is essential. A catheter is unsatisfactory for this 
purpose becau.se the patient emerging from 
anesthesia damps his jaws and bites down 
upon it. Besides, catheters are limp and are 
difficult to direct into the pharynx in order to 
accomplish thorough cleansing. 

3. The operation should alwavs be per- 
formed on a table which can he tilted to the 
head-down position in the event smmiting 
occurs so that aspiration is prevented by allow- 
ing the stomach contents to gravitate into the 
nasopharynx. 

4. Flammable anesthetics are not used in 
situations in which a fire hazard exists. Ex- 
plosions may cause death of the patient by rup- 
ture of the trachea, alveoli and other mani- 
festations of a blast injury. Operating room 
personnel are not immune from injury. 

5. Premedication should always be given if 
possible. Attempts to anesthetize patients with- 
out adequate premedication lead to unsatisfac- 
tory results. 

6. The anesthetic should be administered by 
one trained in the principles of anesthesia. The 
tendency to consider anesthesia lightly is all 
too pre\ulent. xA procedure of minor conse- 
quence from a surgical ^aewpoint may become 
a major one when performed under general 
anesthesia. The practice of relegating the ad- 
ministration of anesthetics to interns and other 
personnel not familiar with the fundamentals 
of anesthesia should be condemned. General 
anesthesia should not be administered bv per- 
sons not familiar with the basic principles of 
anesthesia, and resuscitation. Generally, physi- 
cians instructed in this aspect of medicine ad- 
minister anesthetics. However, the demand for 
personnel to administer anesthetics is so ^great 
that nurses are also taught the basic prin^ples, 
and administer anesthetics under supervision 
and direction of the surgeon. 

7. General anesthetics are not administered 
in situations in which no provision is made for 
recovery from its effects. A recovery room with 
a bed, suction, emesis basins and all the neces- 
sary resuscitative paraphernalia is highly 
desirable. 



184 


Chapter 7 . Anesthesiology 



Figure 5. The Sylvester method for performing artificial respiration, a, inspiration is accoini'ilislied by 
extending the arms over the patients head, b, Ex'piration is accomxriished by coin[)res.sing the elbnv\'s along 
the lower chest wall. This method is adaptable during surgery when no other iminecliatc metlitKl < 1 !' resuscita 
tion is available. (Author’s article in Oschner and DeBakey: Christopher's Minor Surgery, 7th ed.J 


RESUSCITATION 

Resuscitation is the restoration to life of the 
apparent dead. In no aspect of medicine do 
situations requiring resuscitation arise as fre- 
quently as they do in anesthesia. There are two 
phases to resuscitation: ventilatory, which 
is artificial respiration for apnea, and 
which is an attempt to reactivate a heart which 
has ceased to beat. 

Ventilatory Resuscitation. Whenever \^en- 
tilatory efforts cease, irrespective of the cause, 
artificial respiration is indicated. The most prac- 
tical and effective method of artificial respira- 
tion in operating rooms is the intermittent in- 
sufflation technique. The mask of the inhaler 
of the anesthesia apparatus is held firmly on 
the patients face and the rubber breathing bag 
is compressed rhythmically sixteen to twenty 
times per minute. Inspiration is active, expira- 
tion is passive, owing to the elastic recoil of the 
lungs. The iron lung and other mechanical res- 
pirators are used only for protracted periods of 
artificial respiration. When an anesthesia ap- 
paratus is not available, manual methods may 
be used. The most practical for the operating' 
room is Sylvester's method because it is per- 
formed with the patient in the supine position 
(Fig. 5). The patient's wrists are grasped by 
the operator standing at the head of the operat- 
ing table. The thorax is compressed with the 
patients elbows. The arms are then extended 
over the patients head to inflate the thorax. 
The procedure is repeated fifteen to twenty 
times per minute. The arm-lift back-pressure 
method of Neilsen may he used for the prone 
position. Mouth-to-mouth breathing is an often 
forgotten effective method. The operator in- 


flates the lungs by placing his lips to those ol 
the patient and pinching the nose, 'loo often 
rcsuscitative efforts fail because they arc not 
instituted soon enough and because the airway 
is poor. Respiratory stimulants are rarely of any 
value for resuscitation. 

Cardiac Resuscitation. The term 'Vtircliac 
arrest’' is used to designate unexpected cessa- 
tion of effective cardiac actit'ity occurring in 
the operating room or immediately after op* 
eration. The causes of cardiac arrest ha\’e been 
enumerated in the discussion of operating room 
fatalities. When cardiac arrest is suspected, tiu' 
chest should be opened immediately and at- 
tempts made to resuscitate the heart. Curdiac 
arrest is due to asystole or ventricular filirilla- 
tion. It is imperative that massage be instituted 
as quickly as possible so that an dfective head 
of blood pressure is maintained in the vascular 
system. Artificial respiration must be carried on 
simultaneously to provide proper oxygenation. 
Unless resuscitation is instituted immetliately, 
cerebral damage invariably results if the pa- 
tient survives. 

The technique of cardiac resuscitation is 
simple. An incision is made between the fifth 
and sixth ribs on the left side from a point 
one inch lateral to the sternum to tivoicl the 
internal mammary vessels. The heart is grasped 
between both hands and compressed rhytln 
mically at a rate as near normal as is possible 
so that an effective arterial pressure is main- 
tained. If the myocardium is atonic and de- 
pressed, 0.25 mg. epinephrine (1:1000) or 5 
cc. of 5 per cent calcium chloride is injected 
into the right atrium. Physical methods are 
necessary to reverse ventricular fibrillation; 




Resuscitation 185 


drugs are ineffective. The heart is shocked with 
the ordinary 110 volt-60 cycle alternating cur- 
rent. The shocks, 11{> amperes for one-tenth 
second, are delivered by broad electrodes 
placed over the surface of the heart. Asystole 
de^^elops after se^^eral shocks and massage is 
maintained until the beat resumes. Defibrilla- 
tors specifically designed for the purpose are 
now available which should be a part of emer- 
gency operating room equipment. 


READING REFERENCES 

Adams, R. C.: Intravenous Anesthesia. New York, Paul 
B. Hoeber, Inc., 1944. 

Adriani, J.: The Chemistr>^ of Anesthesia. SpringBeld, 
III, Charles C Thomas, Publisher, 1946. 

Adriani, j.: The Techniques and Procedures of Anes- 
thesia. Springfield, Ilk, Charles C Thomas, Pub- 
lisher, 1947, p. 173. 

""Adriani, ].: Local and Regional Anesthesia for Minor 
Surgery. S. Clin. North America 31:1507, 1951. 

Adriani, ].: Deaths from Anesthesia. M. Times, New 
York, June, 1952. 

Adriani, ].: The Pharmacalogy of Anesthetic Drugs, 
3rd ed. Springfield, Ilk, Charles C Thomas, Pub- 
lisher, 1953, pp. 3-7. 

Adriani, J.: Nerve Blocks. Springfield, III, Charles C 
Thomas, Publisher, 1954. 

Adriani, J.: The Selection of Anesthesia: Its Pharma- 
cological and Physiological Basis. Springfield, III, 
Charles C Thomas, Publisher, 1955. 

Adriani, John, and Roman, D. A.: Saddle Block Anes- 
thesia. Am. J. Surg. 71:12-18, 1946. 

Alexander, F. D. A., and Cullen, S. C.: Premedication. 
Am, J. Surg. 34:428, 1936. 

A.M.A. Fundamentals of Anesthesia, 3rd ed. Philadel- 
phia, W. B. Saunders Company, 1954. 

Beecher, H. K.: Anesthesia for Thoracic Surgery. 
Springfield, 111., Charles C Thomas, Publisher, 
1952. 

Beecher, H. K., and Adams, R.: Ether Anesthesia in 
the Presence of Pulmonary Tuberculosis. J.A.M.A. 
]I8;1204, 1942. 

Bonica, J.: Management of Pain. Philadelphia, Lea & 
Febiger, 1953. 

Brewer, N., Luckhardt, A. B., Least, W. N., and 
Bryant, D. S.: Reflex of the Glottis by Stimulation 
of Visceral Afferent Nerves. Anesth. & Anaig. 13: 
257, 1934. 

Burstein, C. L.: Fundamental Considerations in Anes- 
thesia. New York, The Macmillan Company, 1950. 

Clement, F.: Nitrous Oxide Anesthesia. PhOadelphia, 
Lea & Febiger, 1952. 

Collins, V, J. : Principles and Practice of Anesthesiology. 
Philadelphia, Lea Sc Febiger, 1952. 

Courville, C. G.: Untoward Effects of Nitrous Oxide 
Anesthesia. Mountain View, California, Pacific Press 
Publishing Association, 1939. 

Courville, C. B., and Batten, C. T.: Mental Disturb- 


ances Following Nitrous Oxide Anesthesia. Anes- 
thesiolog>' 1:261-273, 1940, 

Cullen, S.: Anesthesia in General Practice. Chicago, 
Year Book Publishers, Inc., 1946. 

Dripps, R. D.: The Immediate Decrease in Blood Pres- 
sure Seen at the Conclusion of Cyclopropane Anes- 
thesia. Anesthesiolog}- 8:15-31, 1947. 

Foldes, F. F.: Some Problems of Geriatric Anesthesia. 
Anesthesiolog}’ 11:737-744, 1950. 

Gillespie, N. A.: Signs of Anesthesia. Anesth, Sc Anaig. 
22:275, 1943. 

Gillespie, N. A.: Endotracheal /\nesthesia. Madison, 
University of Wisconsin Press, 1948. 

Graubard, D., and Petersen, M.: Intravenous Procaine. 
Springfield, 111, Charles C Thomas, Publisher, 1950. 

Griggs, T„ Adriani, J., and Berson. \\ .: Aids to 
Pediatric Anesthesia. Anesth. & Anaig. 32:340, 1953. 

Guedel, A. E,: Inhalation Anesthesia. New York, The 
Macmillan Company, 1950. 

Hale, D.: Anesthesiolog>'. Philadelphia, F. A. Davis 
Company, 1954. 

Hampton, J, L., and Little, D. M.: Controlled Hypo- 
tension in Anesthesia. Lancet 1:1299, 1953. 

Hirschfelder, A. D., and Bieter, R. N.: Local Anes- 
thetics. Physiol. Rev. 12:190, 1932. 

Kurtz, C. M., Bennett, J. H., and Shapiro, H. H.: Elec- 
trocardiographic Studies during Surgical Anesthesia. 
J.A.M.A. 106:434, 1936. 

Labat, G.: Regional x^nesthesia, 1st ed. Philadelphia, 
W. B. Saunders Company, 1927. 

Leigh, yi. D., and Belton, M. K.: Pediatric Anesthesia. 
New York, The Macmillan Company, 1949. 

Lur«dy, J. S.: Clinical Anesthesia. Philadelphia, W. B. 
Saunders Company, 1942. 

Papper, E. M.: Renal Function during General /\nes' 
thesiain Operation. J.A.M.A. 152:1686, 1953. 

Robbins, B. H.: Cyclopropane Anesthesia. Baltimore, 
Williams & Wilkins Company, 1940. 

Robbins, B. H., and Lundy, J. A.: Curare and Curare- 
like Compounds. Anesthesiology 8:348-357, 1947. 

Rupp, R. E.: Modern Concepts of Refrigeration Anes- 
thesia. Anesth. & Anaig. 22:18, 1943. 

Saklad, M.: Grading Patients for Surgical Procedures. 
Anesthesiology 2:281, 1943, 

Seevers, M. H., and Waters, R. ki: Pharmacology of 
Anesthetic Gases. Physiol. Rev. i 8:447, 1938. 

Slocum, H. C., Hoeflich, E. A., and Allen, C. R.: Cir- 
culatoiy and Respiratory Distress from Extreme Posi- 
tion on the Operating Table. Surg., Gynec. & Obst, 
84:1051, 1947. 

Smith, H. Wk, Rovenstine, E. A., Goldring, W., et al: 
The Effect of Spinal Anesthesia on the Circulation 
in Normal Unoperated Man with Reference to Au- 
tonomy of the Arterioles and Especially Those of the 
Renal Circulation. J. Clin. Investigation 18:319, 
1939. 

Stephen, R.: Elements of Pediatric Anesthesia. Spring- 
field, III, Charles C Thomas, Publisher, 1954. 

Virtue, R.: Hypothermia. Springfield, Ilk, Charles C 
Thomas, Publisher, 1955. 

Waters, R. M., Orth, 0. S., and Gillespie, N. A.: 
Trichlorethylene Anesthesia and Cardiac Rhythm. 
Anesthesiology 4:1-5, 1943. 



Basic Principles of Technique 
in Surgical Care 

By B. F. LOLINSBLIRY, M.l), 

Benjamin Franklin Lounsbury is the soti (jf a siuffcou and received his eduentio}} 
at the University of Wisconsin and Narllnvcsteni University. Dr. I ounshury is close 
enough to the age group of residents and iioenis in surgery to he fHirticiihirlr suited 
to describe procedures about which they ate often in doubt. One may he well versed 
m the principles of the care of catastroynic surgical situations, and yet he i/uite 
ignorant of the nietlculous methods which, when applied promptly and judiciously, 
prevent the crippling complications which too often follow cm apparently simple 
surgical lesion. 


EMERGENCY ROOM PROCEDUR]fi 

Every member of the house staff in We aver- 
age general hospital is certain at sopie time 
during his career to face a situation in the 
emergency room in which he is presontecl with 
a critically ill or injured patient whose life may 
depend upon the young surgeon's accurate and 
quick appraisal of the problems and rapid insti- 
tution of therapy. 

Examination of Patient. Although an 
emergency examination must of necessity be 
rapid and less detailed than the more leisurely, 
intricate procedures through which the doctor 
puts a patient in his office, or by which he 
examines the hospitalized but not acutely ill 
patient, nevertheless, it must be a searching 
examination which will disclose within a mat- 
ter of moments the essential pathology. It does 
help if some bystander who witnessed the 
accident, or a relative who is familiar with the 
patients medical history, can furnish some 
pertinent data, but this information must not 
he obtained at the expense of the examination 
of the patient, 

While the examiner is feeling the pulsi^he 
can observe the character of ^piratlon” If the 
patient is in coma, and particularly if he is 

Page 


having labored respiration, the examiner mu. 
satisfy himsell that there is no obstruction c 
the airway, llie tongue should l)e pulled foi 
ward, and if this does not reliew* res [){ ration i 
may be that the [)atient has already aspiratec 
mucus. The chest should be auscultated foi 
breath sounds to see whether the air i.s actually 
getting ilifdDgh into a lung. If there is any 
doubt, the trachea should be asihrated with a 
small-caliber catheter attached to a suetitni appa- 
ratus. In the conscious patient, continuing diffi- 
culty in respiration with cyanosis should suggest 
the possibility of tension pneumothorax, cardiac 
failure, a sucking wound of the cTiest, or some 
other acute process changing the intrathoracic 
physiology, If a determination of the pulse has 
established that the patient is not in cardiac 
arrest, or in severe cardiovascular collapse, the 
remainder of the examination can be carried 
out and the information about the cardiac 
status mentally fitted into the rest of the pic- 
ture assemblccl by the continuing examination. 

After the pulse and respiration have been ; 
checked the head is examined. It is {xissible to 
palpate the cranium quickly and thoroiiglily i 
in a matter of moments in a search for lacera- ! 
tions, contusions and swelling. One should } 

186 1 



187 


Emergency Room Procedures 


look particularly for fluid issuing Ironi the nose 
or ears. The size and regularitv of the pupils 
should be noted, as well as any facial as}m- 
metry appearing on simple examination, the 
cervical spinous processes posteriorly and the 
trachea and thyroid cartilages anteriorly can be 
gently but easily palpated for evidence of asym- 
metry. In almost the same gesture the neck can 
be palpated for evidence of crepitation. 

1 he chest should then be examined carefully 
for evidence of wounds and a series of respira- 
tory excursions should be watched. Breath 
sounds should be listened for on each side of 
the chest in representative areas and the heart 
tones should he briefly noted in the significant 
areas at apex and base. The examining Anger 
can he run lightly but quickly over the rib cage 
on each side for evidence of rib fracture or 
subcutaneous emphysema. As the examination 
is carried posteriorly the scapulae should be 
felt on each side and then, anteriorly, the clavi- 
cles. As the examiner’s hands are passed later- 
ally along the clavicle, a gross survey of the 
structures around the shoulder joints can be 
easily made. At this point both upper extremi- 
ties should be quickly and deftly palpated for 
gross evidence of a fracture by moving the 
humerus about its articulation with the clavi- 
cle and scapula, and subsequently moving the 
forearm on the arm at the elbow in extension 
ahd flexion as well as in supination and prona- 
tion. 

The patient s hands should be moved in all 
possible directions at the wrist. Most fractures 
involving the bones of the hand are apparent 
in the slight deformity or asymmetry produced 
in the area of the fracture. Thus, a fracture of 
the fifth metacarpal, unless it is impacted in 
good position, will produce a shortening of the 
fr :h finger as the fingers are bent into the palm 
•and will obscure the normal protrusion at the 
end of the fifth metacarpal. If the patient is 
conscious, he should be asked to make some of 
the movements of the hand which would 
indicate involvement of the median, ulnar or 
radial nerves. These movements are opposition 
of the thumb, or tip of the thumb to tip of the 
little finger, as a check for median nerve func- 
tion; extension of the hand at the wmst, or the 
thumb at the metacarpophalangeal joint, as a 
test of radial nerve function; and alternate 
ulnarward and radialward deviation of the 
fully extended fingers as indication of ulnar 
nerve function. 

If the patient is unconscious, weakness or 


paralysis of the upper extremit\ can be deter- 
mined if the arm is raised passively abo\T the 
patients face, and allowed to fall. If norma! 
muscle tone is present the extremity will not 
strike the examiners hand which protects the 
patient's face, but will a\'oid it. 

Examination of the abdomen is important in 
the conscious as well as in the unconscious 
patient. First, simple visual examination should 
be employed to determine vdiether the abdo- 
men is scaphoid or distended, and whether its 
movements are normal for a patient who is 
breathing normally with an uninvoited dia- 
phragm. Next, the abdomen should be pal- 
pated for muscle guarding, tenderness and 
masses. The conscious patient can gi^'e con- 
siderable help by indicating whether or not 
there is tenderness in the abdomen and if so 
exactly where, as well as whether the tender- 
ness is rebound in character. The palpation of 
the abdomen can be combined with gentle 
compression of the thoracic cage from side to 
side as a gross method of determining the 
possibility of rib fracture. If the abdomen is 
distended and the patient is unconscious, the 
abdominal examination should be extended to 
include careful auscultation of bowel sounds. 
If the patient is conscious and does not com- 
plain in particular of the abdomen, this phase 
of the examination may be postponed pending 
completion of the cursory examination of the 
lower extremities. 

The pubic symphysis should be gently pal- 
pated and pressed against, just as the iliac 
crests should be subjected to gentle compres- 
sion, in an effort to determine grossly whether 
or not there is a pelvic fracture. Both inguinal 
areas should be inspected and palpated for the 
possibility of a strangulated inguinal hernia. 
It is important to examine the perineum and 
buttocks in both male and female patients for 
any evidence of contusions and, particularly, 
for any evidence of wounds which might in- 
volve the rectum at a higher level. The scrotum 
should be quickly palpated and the external 
urethral meatus of the male examined for gross 
evidence of bleeding. In female patients, the 
labia should be gently separated and the 
urethral orifice and introitus briefly inspected. 

At this point attention can be directed to 
the lower extremities as the final part of the 
emergency examination. The contour and sym- 
metry of these extremities should be examined 
and then the tissue should be palpated gently 
but definitely in search for evidence of fracture 



188 Chapter 8, Basic Principles of Technique in Surgical Care 


of any of the long bones, in the conscious 
patient, voluntary effort should be requested 
to see that there is no limitation of motion of 
any of the major muscle groups or of any joints. 
In the unconscious patient, the thigh should be 
flexed passively on the abdomen with the heel 
still on the examining table and then released 
to determine whether the extremity will slide 
down in an abducted position indicative of 
paralysis. 

Care of Simple Wounds. In the average 
hospital, simple wounds such as lacerations, 
contusions and even minor avulsions are treated 
in the emergency room, A simple rule of thumb 
for determining whether an injury is serious 
enough to require formal treatment in the 
operating room is that the latter is reserved for 
injuries in which deeper structures such as 
tendons, nerves, bones and blood vessels arc 
involved. Obviously, head wounds of any 
severity, chest wounds, abdominal wounds, 
compound fractures and even simple lacera- 
tions of any great length or depth will require 
formal debridement and repair in a bcttcr- 
operating room as opposed to the 
more simple outfitted emergency room. 

All wounds should be gently cleansed with 
soap and water. This is best done by covering 
the actual wound with a simple, sterile gauze 
dressing while the skin about it is initially and 
briefly cleansed with soap and water, using 
frequent irrigations of soapy water or normal 
saline solutions from a separate container. 
When the skin adjacent to the wound has thus 
been cleansed, the wound itself should be 
similarly washed with soap and water and irri- 
gated with saline solution. Irrigation is particu- 
larly important in wounds which have some 
depth, or in which there has been considerable 
contusion of the soft tissue with indriven dirt 
and similar debris. It is usually accepted that a 
ten-minute cleansing with soap and water 
coupled with saline irrigation provides the 
optimum preparation of the wound. At this 
point the devitalized tissue should be excised 
and the various layers involved should be gen- 
tly debrided, trimming away only the jagged 
and irregular edges and those pieces of skin, fat 
or muscle which are either obviously dead or so 
badly contused that their recovery is question- 

Insofar as ;^ssihle all foreign material should 
be removed. This is particularly true of cloth- 
ing, hair and street dirt. However, considerable 
judgment must be exercised because sometimes 


a search for an ibinocuous foreign bock', slicIi as 
a small piece of metal which was hoi al the 
time of its entr\a may he more deeaslatiiig to 
the tissue than simply leaving the foreign body 
in place. In some abrading iniuric's tlic’re is a 
great deal of tattooing of the skin in its nion- 
superficial layers. landless time can he spetU in 
attempting to pick out these small picxv's of 
gravel or dirt, wdiercas most of thcan will slough 
if they arc simply left alone and allowed to 
work out as the cells in which iliev are im 
bedded arc pushed out l()v\’ard the epidermis. 

In wounds which ha\'e been ad(‘(juately 
cleansed and debrided and which art* seen 
within six to eight hours of their inlliolion, it is 
perfectly safe to close the skin edges primarily. 
In wounds vvhicli are seen after this "golden 
period’ has passed, it is probably safc’st to leave 
the wound edges ()[xm. If upon inspection a 
week to ten days later tht' wound is elinieally 
clean, it may be possible to close it seeondarily 
as was done with many thousands of wounds 
in World War 11 tincl tiie Korean cofilliet. d he 
closure need not in\'()lvc‘ actual suturing be- 
cause sometimes sterile tape hriclgt*s, or col- 
lodion-impregnatccl (ine-inesh gau/r hritlges, 
can be used to approximate these skin edges 
almost as dfectively as actual suture* matt'rial. 

Care of Animal Bites. A wound pmclueed 
by animal bite presents particular prohk'tns not 
usually present in wounds inflicted by inani- 
mate objects. Dog bites are by lar tht* cotnnion- 
est of animal bites and they *tilwtiys carr\^ with 
them the risk of rabies. All sueb aitimal bites 
must be reported to the proper aulliorities, 
usually the local police sttition or in some com- 
munities it is required that the l>jtc bt* reported 
to the Public Health Department directly. 

The wound is treated like any other wound 
and when adequately debrided aitd cleansed it 
may be closed primarily if it is seen .sufftciently 
early. Special problems concerning <log bitc.s , 
revolve about the cjucstion of whether or not : 
the dog is rabid. If the dog can he positively 
identified and kept under obseri'ation, the pa* 
ti^t need not be given any proj)hylaxis against j 
taoies. If the dog was in a pre rabid pliase of , 
the disease at the time the wound was inflicted, "j 
the animal can be expected to dei'elop clinical j 
signs of rabies within ten to fifteen days. At i 
this time positive immunr/ution of the patient ; 
with rabies vaccine can still be successfully ! 
undertaken. If the dog does not develop rabies j 
during the period of observation, then the mat- ! 
ter can be dropped. j 



189 


Emergency Room Procedures 


Technically, human bites are in man\ \va\s 
much more serious than the average animal 
bite because the symbiotic action of \hncent’s 
organisms found in the mouth of the human 
being produces an extremely virulent infection. 
For this reason, human bites must be gh’en 
especially meticulous care and in most instances 
should not be closed primarily even if seen 
eaily. 

Bites by other animals are quite infrequent 
but in many instances carry the same danger 
of rabies as do dog bites. Squirrels, skunks, cats, 
and other small animals have been known to 
transmit rabies to human beings. In the in- 
stance of a bite from such a small animal, if the 
animal can be kept under observation the same 
procedure is followed as that in the dog. In 
most instances, however, it is impossible to 
make a positive identification of the animal, 
much less keep it under observation. Therefore, 
to be on the safe side, individuals bitten by 
such animals should be given the Pasteur anti- 
rabies treatment. 

Protection against Tetanus, hlany wounds 
carry with them the potential danger of tetanus. 
This is particularly true of wounds inflicted by 
rusty implements or nails and of wounds con- 
taminated with street dirt or farm dirt. The 
spores of tetanus are known to be widely dis- 
tributed in nature and to occur as contaminants 
of various animal furs and hairs. Since tetanus 
organisms are anaerobic, they wall multiply 
best and elaborate their toxin in the depths of 
a closed wound. It is possible that they thrive 
even better in an infected w^ound where other 
pathogens are present to use the oxygen, thus 
producing a more truly anaerobic environment. 
Thus, one form of prophylaxis against tetanus 
consists of removing so far as possible contam- 
ination in the depths of the wound and in 
every way possible preventing any wound in- 
fection; however, this alone is not sufficient 
because tetanus carries such a high mortality 
when it does occur. Therefore, two means of 
giving the wounded individual immunity are 
in iise. The first is to confer passive immunity 
by means of tetanus antitoxin, and the second 
is that of developing the patiends own active 
immunity to tetanus by means of tetanus 
toxoid. 

An effective passive immunization wdiich 
will last for at least one week can be conferred 
on an individual by giving tetanus antitoxin 
which is derived from the serum of horses. The 
standard dose has been 1500 units, but many 


plnsicians imu are giving a minimum of 3000 
units and some give 5000 units. This confers 
immunization immediately, but immunization 
is not effective longer than one week so that 
if the wound for which this w^as given con- 
tinues to be infected the dosage of tetanus 
antitoxin must be repeated. Because there is an 
appreciable incidence of sensitivity to horse 
serum, tetanus antitoxin should not be given to a 
patient without first testing the individual for 
sensitivity. This may be done by means of 
intradermal tests or, as some authorities feel, 
more effecti\^ely by means of conjunctival tests 
in which a drop or so of very weak solution of 
antitoxin is used. If there is a sensitivity and 
the situation requires definite!}' that antitoxin 
be gi\’en, it can be given in very small doses 
with some intravenous antihistamines and/or 
5 ram. of 1 : 1000 Adrenalin chloride. In some 
instances it may be necessary to use a rapid 
desensitization procedure. 

Tetanus toxoid is an alum-precipitated sus- 
pension of killed organisms of tetanus which 
is gi\^en in a series of three doses, usually at 
weekly or biweekly intervals to develop the 
individual’s own immunity to tetanus. This 
procedure has many advantages over immuni- 
zation with tetanus antitoxin, not the least of 
which is the fact that there is no real sensitivity 
to the tetanus toxoid. Occasionally, a patient 
may develop a local reaction at the site of injec- 
tion but this is transient and is never accom- 
panied by systemic signs. Another advantage 
of tetanus toxoid is that the titer of immunity 
so produced can be raised to an effective level 
with a so-called booster dose of 0.5 cc. of toxoid 
at long intervals after the original immuniza- 
tion series has been given. Authorities now feel 
that there is still a responsive level almost ten 
years after the original series of immunizations. 
It might be pointed out that tetanus toxoid can- 
not be invoked as a means of protection against 
a particular wound. If the patient has not been 
previously immunized with tetanus toxoid, the 
level of antibody rises so slowly that it will not 
be effective in the particular instance where the 
possibility of tetanus is feared. Immunization 
with tetanus toxoid is definitely an interval 
procedure which is done in anticipation of the 
patient’s receiving wounds in the future which 
might carry the risk of tetanus. Practically all 
youngsters today who are under the care of a 
family pediatrician are routinely immunized 
against tetanus. All persons entering the Armed 
Forces of the United States similarly receive 



190 


Chapter 8. Basic Principles c 

immunization with tetanus toxoid so it is a 
relatively easy matter to determine whether or 
not an individual has had a previous immuni- 
zation. If he has, then a booster dose of tetanus 
toxoid is all that is needed. 

Care of Severe Injuries. When the house 
officer is confronted with a severe injury which 
requires care in the operating room, he must 
have a deffnite logical approach to the problem. 
This should have been thought out and 
planned in adtnnce to the extent that it is al- 
most second nature with him. 1 he basic tenets 
of this approach are; keep the patient alive; 
find out what is the matter with him; get 
whate^'er help is needed; restore normal physi- 
ology as soon as possible. Ihc tenets are listed 
in the order of their priority although they 
are obviously not mutually exclusive. 

Although usually it is fairly obvious what 
must be done to keep the patient alive, occa- 
sionally, as in the instance of severe spontane- 
ous pneumothorax or a recently perforating 
ulcer, the young surgeon may have to do a little 
searching to find exactly what is wrong with 
the patient before he can attempt to save his 
life. It may seem to some that the statement of 
such four tenets is unnecessarily Fundamental. 
However, there are few surgeons who have not 
had the experience of seeing a befuddled 
intern, stunned by newspaper reporters and 
photographers, trying to placate the weeping 
relatives while attempting in his own mind to 
decide whether to summon an attending man, 
call the operating room, take the patient to the 
x-ray room, or try to obtain a history. Such an 
intern, remembering these tenets, would imme- 
diately clear the emergency room of all rela- 
tives, bystanders, photographers and police 
while he made a rapid assessment of the pa- 
tient’s vital signs and determined the degree of 
jeopardy. He would then institute symptomatic 
therapy for what seemed to him most threaten- 
ing-oxygen for obvious respiratory distress; 
intravenous fluids for signs of shock— while 
having a sample of blood taken for immediate 
typing and crossmatching. He could then sum- 
mon an appropriate attending man and send a 
nurse or emergency room aide out to ask the 
relatives or bystanders a few simple questions 
to fill in the clinical picture already developing 
from his findings gleaned while he conducted 
the remainder of his emergency examination. 
Fulfillment of the final tenet usually involves 
definitive treatment surgically or medically, as 
the case may be-slow decompression of the 


■ Technique in Surgical Care 

affected lung in the s[v)iUanc()iis lyncumo- 
thorax, closure of the hole in die duodenum in 
the iiistuiicc ol a pcrioruliiig iih^u alignment 
and immobilization ol the Iragincnts ol a Irac- 
tured bone, or ligation of a se\mvd artei\' in the 
instance of scn^crc hemorrhage Ironi a lacera- 
tion. The intern or resident, howevet iiu’xpcri- 
cnccd he ma> be in handling cmeigeneies, who 
knows what needs to l;>e done and has a syste- 
matic way ol achieving his oDjeetnes nui\' be 
able to do as much (or the se\c‘ix’l\' injured or 
acutely ill patient as the most skilletl and ex- 
perienced physician. This matter of having a 
system lor handling cnicrgc'nei(‘s, a pattcun (or 
activity in the face of life-threatening wounds 
and iilnesscs becomes even more important 
when the hosifital is suddenly confronted with 
a mass influx ol patients Ironi some local catas- 
trophe such as a fire, explosion, hurricane, 
flood, or similar misfortune. 01 course, the im- 
plications as to the importanet* ol orderly think- 
ing and systematic action in tiie lace o( such a 
catastrc)])he as enemy bombing (>1 oiu' ol our 
cities are all too dear. 

VENIPIINCTIIRK 

Perhaps the most important leature ol veni- 
puncture is selecting an appiopriate vein. Since 
ihc antccubital x'cins are usualk tpiite jiromf 
Bent and fairly easily entenxfi they are ollen 
used For withdrawing blood samples. 1 lowevcr, 
the amount of motion possible at the elbow 
makes them p{)orly suited for continuous intra- 
venous infusion. /VLso, in a patient who is to 
require intravenous fluids o\'er a period of 
many days, it is wiser to start as lar ptadplicrally 
as possible so tliat as thromlxJKis occurs there 
will still be veins a\'ailab!e proximalward from 
the site of the first venodysis. In general, the 
superficial veins on the flexor and extensor 
surfaces of the forearm arc best for the admiiv 
istration of intravenous lluids. I lowcn'cr, the 
veins of the foot arc often easily used, and the 
constancy and size of the greater saphent)us 
vein at the medial malleolus rnakt*s it a fre- 
quent site of election for venodysis, particu- 
larly when this is accomplished l)y cut-down 
and the placing of a cannula. 

Obviously, the vein must be Full to be 
located and particularly to be entered by tk 
needle. Superficial veins are best filled by 
occluding their centripetal How t)y means of t 
blood pressure cuff placed above the vein an< 
inflated to a pressure of 40 mm. of mcrcur) 
Usually, it is not necessary to invoke such a: 



Venipuncture 191 


elaborate procedure and an ordinary tourniquet 
can be gently tightened around the arm or leg 
above the place where the \enipuncture is to 
be done. Active or passive contraction of a 
muscle distal to this tourniquet will free more 
blood to fill the chosen vein. 

Different individuals have different ways of 
making the actual introduction of the needle 
into the lumen of the vein. The beginner will 
do well to bear several fundamental facts in 
mind. First, the segment of vein which is to be 
entered must be relatively fixed so as to offer 
some resistance to the point of the needle. This 
fixation is best accomplished by drawing back 
on the skin over the vein at a distance of 1 to 2 
inches below the projected site of puncture; 
this leaves a segment still filled with blood 
relatively fixed so that it does not roll over the 
point of the needle (Fig. 1). Second, when it 
is felt that the point of the needle lies against 
the wall of the vein a short, swift jab is re- 
quired to put the point of the needle, which is 
impinged against the wall, actually through the 
wall. A little experience will teach the beginner 
much about the amount of force that is re- 
quired for this maneuver. However, the stroke 
should be short so that the needle does not go 
completely through both walls of the vein and 
it should be directed at an acute angle to the 
vein wall, preferably with the open end of the 
needle facing out away from the vein wall in- 
stead of down and parallel to it. Once the tip of 
the needle is in the vein a meticulous effort 
should be made to feed the needle slowly into 
the lumen of the vein so that at least an inch 
of it is inside the lumen. With the needle held 
at its point of entrance through the vein wall, 
this gives a long arm and consequently poor 
mechanical advantage to any movements which 
might force the tip of the needle through the 
vein at still another point; consequently it 
makes it much less likely that the needle will 
come out of the vein or that there will he any 
extravasation. 

The moment of entry of the needle through 
the vein wall is usually signaled by the appear- 
ance of a small spurt of blood just proximal to 
the hub of the needle within the syringe or the 
intravenous tubing. If one feels that the needle 
is in the vein and yet the spurt of blood fails 
to appear, gentle traction may be made on the 
column of blood by pulling back on the plun- 
ger of the syringe or by milking back on the 
tubing to invoke such an outpouring. If blood 
still fails to appear and one is still certain that 



tbe needle is within the lumen of the vein, the 
injection should be given slowly or the clamp 
on the intravenous fluids released to allow flow 
of a small amount of fluid. If the needle is out 
of the vein, there will be immediately a swell- 
ing at the site where the fluid is being deposited 
outside the vein wall. In this event the veni- 
puncture must be attempted again at a point 
proximal to the point of failure. The latter 
point, the site of the original entry, should be 
covered with a small dressing and pressure 
maintained to prevent undue extravasation of 
blood through the point of rupture of the vein 
wall. 

Once the needle is w^ell established in the 
lumen of the vein, it must be fixed to tbe skin 
to prevent its being dislodged subsequently. 
This is best done by placing a small gauze pad 
under the hub of the needle and then placing 
adhesive tape over the hub and gauze to hold 
the needle down against the skin. Additional 
pieces of tape should be used to hold the intra- 
venous tubing to the skin at a point 3 to 4 
inches beyond the site where the needle en- 
tered the vein. In all this taping and position- 
ing of the needle, one must be sure that the tip 
of the needle is not angulated against the wall 
of the vein or that the pressure is not so severe 
as to cause the needle to push the vein wall 
down into the tissues beneath it and thus oc- 
clude the fiow^ of blood past the needle. 
Observation of the dripping of the fluid within 
the glass chamber beneath the intravenous 
fluid bottle will tell whether the flow of blood 
is being compromised by any of the fixation 
procedures. 

As a final step it may be necessary or desir- 
able to place the extremity used for the intra- 



192 


Chapter 8. Basic Principles of Technique in Surgical Care 



Figure 2. Method of “cut-down” and cannulization 
of vein for introduction of fluids. 


venous administration on an arm-board or other 
splint. This is mandatory, of course, when the 
vein being used is one on the back of the hand 
or on the foot. When the vein is on a relatively 
flat surface on the extensor part of the forearm 
or on the flexor surface, the forearm itself may 
provide sufficient immobilization of the vein. 

‘^Cut-down” and Cannulization of a Vein* 

Occasionally, it is desirable to have a more 
dependable route for administration of intra- 
venous fluids or blood than is afforded by the 
ordinary venoclysis procedure. In such instances 
a vein, usually the greater saphenous at the 
medial malleolus, is exposed by cutting down 
on it after the surrounding area has been locally 
anesthetized. The distal end of the segment 
exposed is then tied and the ligature held with 
a hemostat to provide traction on the proximal 
portion of the vein. Another ligature is passed 
under the proximal end of the exposed segment 
and one tie taken loosely. The middle of the 
exposed segment is then partly cut through 
using a small scissors of the manicure type. The 
V-shaped flap of vein wall thus produced is 
gently lifted up by a small tissue forceps while 
a cannula is slipped into the lumen immedi- 
ately beneath it far enough for the knob on the 
cannula to lie proximal to the loose tie (Fig. 2). 
The tie is then secured by squaring the knot 
and taking an additional loop in that knot. This 
ligature is cut so as to leave the ends 34 to Y) 
inch long. This facilitates the subsequent cut- 
ting of the knot and removal of the cannula 
when the intravenous therapy is to be dis- 
continued. The distal knot is cut flush as it will 


be left in. One or two skin sutures are placed 
in the skin and taken down loosely so that the 
cannula may be subsequently removed and the 
ends of the ligatures then drawn down snugly 
and tied to close the skin wound. It is impor- 
tant to note the location of the greater saphe- 
nous vein before making the cut-down so that 
the incision can be made in the proper place. 
The cut-down should be made parallel to the 
direction of the vein instead of transversely so 
as to facilitate the exposure of a fairly long seg- 
ment of vein through a relatively small skin 
incision paralleling it. A transverse wound 
must be unduly long to permit the exposure of 
an adequate segment of vein. After the cannula 
has been well placed, fluid should be started 
immediately to keep the blood from clotting in 
the cannula. 

CARE OF MECHANICAL EQUIPMENT 

Surgical techniques have now advanced to 
the point where one is often dependent to great 
degrees upon mechanical aids, such as suction 
and tidal drainage systems, sump arrange- 
ments, and underwater drainage bottles like 
those used in draining the pleural space after 
thoracotomy. These mechanical aids are ac- 
cepted and employed so routinely that often it 
is not realized how significantly they may af- 
fect the success or failure of a given operative 
procedure. A simple account of selected inci- 
dents cannot begin to give a connotation of the 
misery for the patient and the heartache for 
the surgeon who are both victims of mechani- 
cal failure, but it may serve to alert the mem- 
bers of the surgical house staff to the impor- 
tance of simple attention to all mechanical aids. 

A patient who had had a subtotal gastrec- 
tomy was returned to his room in good condi- 
tion with the Gomco suction working properly. 
During the course of the remainder of the 
morning and the first two hours of the after- 
noon, the suction did not function well. Un- 
fortunately, no member of the house staff was 
available to examine it or to make sure that it 
was properly irrigated and that its function was 
re-established. When the patient was finally 
seen after 3 p.m., a few blood clots were aspi* 
rated through the small-caliber Levin tube, but 
the patient^s general condition made it obvious 
that he was bleeding into the stomach and that 
large clots had formed making it necessary fot 
him to be returned to the operating room. 
There the gastrojejunostomy was taken down 
and the stomach emptied of approximately 1200 



193 


Surgical Techniques 


cc. of blood, most of which was clotted. \o 
discrete bleeding point was found in the site 
of the anastomosis and the general conclusion 
was that had the suction been working well 
continuously the stomach would not have be- 
come sufficiently distended to allow continued 
oozing from the stoma. 

A patient on whom a mitral valvulotomy had 
been done withstood the procedure quite well. 
Her chest was closed with two drainage tubes 
leading out from the pleural cavity to 1000-cc. 
flasks filled with 700 cc. of sterile water. The 
drainage tube was connected to a piece of glass 
tubing which emptied well beneath the surface 
of the water in the bottle. In one of the bottles 
the glass tube had been cracked at a level above 
that of the water. When the patient w^as being 
put into bed and the jars adjusted on the floor 
the broken piece of glass fell off of its insecure 
connection to the tubing which returned 
through the cork of the bottle. This permitted 
immediate influx of air into the patient's 
pleural cavity and a pneumothorax of several 
thousand cubic centimeters developed almost 
at once in this patient whose condition was 
serious at best. The source of the difficulty was 
immediately detected and the drainage tube 
was clamped until oxygen under pressure could 
be administered through an intratracheal tube 
and the lung blown out at once, as the air 
which had been inadvertently allowed to enter 
was exhausted through the other underwater 
seal. 

An elderly woman who had been subjected 
to choledochotomy for numerous common duct 
stones which had produced jaundice was re- 
turned to her room in fairly good condition but 
had a period during which she was somewhat 
irrational. At this time she managed, in thrash- 
ing around, to pull out the T-tube which had 
been inadequately secured to the skin of the 
abdomen. Another operative procedure w-^as 
required to replace the T-tube, and, of course, 
this second operation was an unnecessary de- 
mand on her feeble reserves. Fortunately she 
survived, but on the seventh postoperative day 
developed a biliary fistula about the T-tube 
which required sump drainage with a Chaffin 
tube and Stedman pump. Because of an un- 
noticed kink in the tube connecting the Chaffin 
sump tube to the pump, no effective pressure 
was put on the sump arrangement for twenty- 
four hours. When it was noticed that there had 
been no drainage accumulating, more careful 
attention was paid to all details of the appara- 


tus and the obstruction was immediately de- 
tected. When this was relieved there was a 
gratiT'ing return through this sump. 

E\'ery surgeon could elaborate at some 
length on this brief list of misadventures result- 
ing from failure of mechanical equipment- 
failure contributed to by the negligence of 
nurses or doctors, failure which should have 
been noticed in time to prevent the difficulties 
enumerated. For example, most surgeons 
ha\^e had T-tiibes and catheters whose lumina 
were plugged with debris the presence of 
which they have detected b\- testing the equip- 
ment before using it. 

Xothing can be taken for granted in the 
utilization of mechanical aids in the care of 
surgical patients. Every piece of equipment 
must be checked before it is used and its con- 
tinuing function must be checked at frequent 
intervals as long as the patient is dependent 
upon that particular equipment. 

SURGICAL TECHNIQUES 

The senior surgical clerk often approaches 
his clerkship in a hospital with little or no 
knowledge of many of the technical procedures 
which he is asked to perform. First-year surgical 
interns who have not had a broad general sur- 
gical clerkship may also have had no contact 
with many of the procedures which are com- 
monly performed in a hospital by a junior 
surgical intern. The techniques of these various 
procedures are obviously best taught person to 
person by one of the surgical residents, or 
attending staff of the hospital, directly to the 
man involved. Of course, there are several 
methods of performing the identical procedure 
to accomplish the same result. 

Surgical Dressings. The application of sur- 
gical dressings is an old and time-honored pro- 
cedure which is done differently by various 
surgeons. The basic principle in applying a 
surgical dressing is that it should be done with 
the same precision and careful attention to 
aseptic technique as is practiced in an operating 
room. Such an exacting end can he achieved by 
the simplest management of details by the 
attending surgical staff with the help of a co- 
operative and intelligent house staff. 

In most modern hospitals, satisfactory provi- 
sions have been made for surgical dressings by 
means of dressing trays or carts. In some insti- 
tutions, individual packages are wrapped with 
materials for individual dressings. Regardless of 
the technique of carrying the dressing equip- 



194 


Chapter 8. Basic Principles of Technique in Surgical Care 


ment and materials to the patient ’s bedside, the 
basic principle should be the same. 

The equipment on the standard surgical 
dressing cart should include sterile canisters 
which contain gauze dressings of various size, 
depending on the particular type of wort being 
done on the service, standard sizes being 3'inch 
and 4-inch square gauzes. There should also be 
canisters containing sterile towels. Other canis- 
ters will be filled with smaller gauze squares, 
sterile test tubes and applicators for the ready 
culturing of secreta from wounds, and various 
types of drainage material which may be needed 
in doing the dressing. A variety of hemostats, 
forceps and scissors should be assembled in a 
flat, sterile, covered basin and there should be 
bottles for the various types of solutions which 
are used in changing dressings. Also included 
should be various types of thicker pads contain- 
ing either cotton or cellulose material, sterile 
and wrapped in toweling. These dressings will 
vary in size depending upon the nature of the 
surgical service. Most surgical dressing carts 
should contain pads, 8 by 12 inches in size, 
which are commonly labeled ^^ABD pads,'’ 
signifying abdominal dressings, but which, of 
course, may be used for other purposes as well. 
At some institutions larger pads of the same 
type are labeled '^arm pads,” since they will 
enclose an entire extremity. When a great 
many burned patients are being taken care of, 
even larger dressings of this same general type 
should be available. Various sizes of gauze, 
roller bandage, elastic bandage, muslin bandage 
and adhesive tape should also be supplied on 
the dressing cart. 

Provision should be made for the collection 
of soiled dressings which should not be allowed 
to touch the bedclothes or the sterile canisters 
on the cart. In some institutions, provision is 
made for these dressings by means of a garbage- 
can type of container on the floor in the hospi- 
tal, or attached to the dressing cart so it may 
easily be removed. This should be covered so 
as to prevent insects from spreading the organ- 
isms about the hospital. Provision is also made 
for the collection of used or soiled instruments 
on the cart which may he returned to the cen- 
tral supply depot for re-sterilization and re-use. 

The solutions on a surgical dressing cart vary 
somewhat with the desires of the particular 
surgeon involved. On most dressing carts, such 
solutions as benzine, acetone and alcohol which 
are necessary in removing, adhesive tape from 
the skin are commonly present. Most modern 


dressing carts do not luivc the stronger antisep- 
tic agents on them since few surgeons employ 
these agents which were so commonly used 
in the past, but they do contain a bottle of 
liquid soap, or one of the emulsil'ying agents, 
for use in cleansing skin. Also a\'ailable should 
be flasks of normal saline solutkm and of 
sterile wmter. There should be a lifting for- 
ceps immersed in alcohol in a jar ol' some type, 
either metal or glass as the case may be. This 
sterile forceps is used for lifting materials from 
the sterile canisters for each dressing st) that the 
canisters will not be contaminated by repeated 
use of the same instrLiments which arc em- 
ployed in doing the dressings. Surgical masks 
should be required supplies; sterile gloves and 
gowns may be provided as desired. 

Regardless of the type of special dressing 
which may be needed in a particular case, the 
technique of handling all dressings should be 
essentially the same. All in attendance, includ- 
ing the patient, should have on a surgical mask 
thereby preventing the contamination of the 
wound by organisms from the mouth and nose. 
At the patient's bedside, a sterile towel is re- 
moved from the canister by means of the lifting 
forceps and spread out on a convenient bedside 
or overbed table. It has been found useful to 
place a piece of folded newspa])cr beneath this 
towel to protect the surface of the table from 
any of the solutions which may reach it. On 
this towel and toward the edge are placed one 
or two sterile hemostats and forceps Irom the 
tray containing the instruments, and scissors if 
these are needed. These instruments arc jilaced 
with the handle- ^dose to the edge so that they 
may be pic^ '"hout contaminating the 

center of the su 4. hies 

of dressings of app ' ' v 

the towel. Then evci * m 

the changing of the di ' 

It should be stressed , 

lutely necessary for adhc , . . 

moved from the patient’s , a 

dressing is changed, it is bettci 
with a pair of bandage scissors ai*^^ge of 
the dressing so as to avoid the irritation caused 
by the repeated application and removal The 
outer part of the old dressing is discarded onto 
a newspaper which can be folded up and 
placed in the receptacle provided for dirty 
dressings. The deeper dressings next to the 
wound are removed by means of the sterile 
instruments , that were placed on the sterile 
towel. 'These^dre^inpsja^^^ dropped, on 



Surgical Techniques 


a paper For discard. Frequently, the first dress- 
ing ma\' be somewhat stiff and adherent to parts 
of the wound owing to the collection of serum 
or even blood which has dried on the dressing. 
As a consequence, the dressing should be re- 
moved cautiously to prevent pain to the patient 
as well as injui}* to a healing wound. Experi- 
ence in doing this thoughtfully and carefully 
with concern ior the patient's comfort increases 
the dexterity and skill of the operator. 

Once the dressing has been removed, the 
wnund may be inspected but should not be 
touched with the fingers since it is regarded as 
relatively sterile. If sutures are to be cut or 
remot’ed, this is done carefully using sterile in- 
struments from the sterile towel and avoiding 
contamination of the working portions of these 
instruments. If the sutures are removed, it is 
often found helpful to apply support to the 
skin which, though healed, may be easily sepa- 
rated by ordinary pull which may produce an 
unnecessarily wide scar. Materials most com- 
monly used for support to the skin are ad- 
hesive bridges made by folding under the por- 
tion of the adhesive tape which will come in 
direct contact with the wound. These bridges 
are made relatively clean by cutting them with 
clean scissors and then painting them with an 
antiseptic solution or flaming them. They are 
applied in such a manner as to take the tension 
from the healing wound. They are particularly 
useful in a long wound and it is better that 
they be applied as the stitches are removed, 
rather than afterwards, since the sudden move- 
ment of the patient may separate the wound. 
Another excellent material for relieving tension 
from the healing wound is fine-mesh gauze, 
usually obtained from roller bandage, which 
has been sterilized and is cut into short strips 
and made adherent to the skin by means of 
flexible collodion applied with sterile applica- 
tors to the whole of each strip of gauze. 

Sufficient gauze dressings are reapplied to 
the wound by means of sterile hemostats or 
thumb forceps to cover the wound adequately. 
This means an overlap at both ends of the 
wound of perhaps 1 or 1% inches and 2 to 3 
inches on each side. This dressing is usually 
covered by an abdominal pad or some thicker 
layer of material wEich prevents further con- 
tamination. 

The smallest amount of fixation possible in 
abdominal wounds is advisable. The amount of 
irritation to the skin from adhesive tape, which 
is most commonly used to fix these dressings in 


195 

place, is reduced by using a minimum of tape. 

1 lowever, tape strips should be long enough to 
fix the dressings well so that they do not slip off. 
The use of any sort of liquid on a healing 
wound that is dry and clean seems superfluous. 
A wound that is open or draining, of course, 
should be cleansed, and the most satisfactory 
materials for this are soap and water, which 
should be sterile, applied with sterile gauze 
sponges held in the hemostats and thumb for- 
ceps supplied on the dressing carts. 

Unused gauze which has not been soiled, but 
has been brought out of the sterile containers, 
is never returned to the containers but is placed 
in a receptacle, provided for that purpose, to be 
returned to the central supply room for re- 
sterilization. 

Although the technique for surgical dress- 
ings described above may seem time-consuming 
to those who have been somewhat less formal 
about dressings, it is a safe and a sure one 
for preventing contamination regardless of the 
type of wound involved, and is a sound one 
for young surgeons to develop. 

Special Types of Dressings. Most surgeons 
have found that mild elastic compression upon 
wounds is helpful in the healing process. This 
is true because support of the venous system, 
particularly in the extremities, improves drain- 
age from the area so that less edema occurs 
and consequently there is a better inflow of 
arterial blood with more effective, rapid heal- 
ing. Compression dressings are often used in 
the treatment of burns on the head, the chest, 
and the extremities. Such dressings are dif- 
ficult or impossible to apply on the abdomen 
and seldom find a useful place there except 
possibly in the instance of burns. The general 
principle in applying a compression dressing 
is that the compression must be uniform and 
not tight in any particular locality so as not to 
obliterate venous return or arterial inflow into 
a part. The gauze dressings are applied in a 
manner basically similar to that used for gen- 
eral dressings. The gauze protective dressing is 
then padded with a mass of either fluffed-up 
dressings derived from '"flats’’ of gauze or, as in 
some institutions, sterile mechanic s waste. An- 
other material often used for compression is 
sponge—either synthetic rubber or sea sponges. 
These materials are then bound down by an 
elastic bandage which may be reinforced or 
tightened by means of safety pins or adhesive 
tape. The materials for an elastic bandage vary 
somewhat with different institutions. 



196 Chapter 8. Basic Principles of Technique in Surgical Care 



Figure 3- Diagram of Cushing type head dressing. 


On the chest the most commonly used ma- 
terials for compression dressings, particularly 
after radical mastectomies and procedures of 
that type, are stockinet of sufficient width, usu- 
ally 6 inches, or elastic bandages which may be 
the two-way stretch type or rubberized elastic 
bandages. The elastic type bandage used on the 
extremities may be of either of these types as 
well An important fact to remember is that 
such a dressing applied to an extremity must 
start at the distal end of the extremity and ex- 
tend proximally as far as desired and not in 
the reverse direction. Leaving an exposed area 
of extremity below such an elastic compression 
dressing usually results in edema and dis- 
comfort and may actually do harm to the 
patient. Elastic type compression bandages 
have a wide usefulness but are particularly 
helpful in the handling of burns and open 
wounds. They also have considerable utility in 
the dressing of any wound about an extremity, 
but one must avoid extreme pressure over the 
bony prominences, which must be well padded. 
The dressing must be applied smoothly and 
without wrinkles which are uncomfortable to 
the patient and may produce undue pressure 
in a particular spot. It is usually applied with- 
out reversing the bandage as is done in plac- 
ing a roller bandage. 

For large wounds of the scalp and for 
craniotomy incisions the most satisfactory dress- 
ing is one designed by Cushing which em- 
ploys a 5-yard roll of sterilized gauze 5 inches 
in width. After applying the original dressing, 
two turns of the 5-yard roll fix the dressing 
about the forehead and occiput. The roll is 
then taken down under the chin and while 
an assistant holds this gauze under the chin 


at a convenient distance so as to prevent mak- 
ing it too tight, two or three turns arc made 
over the vertex so as to cover the remainder of 
the head completely, going under the chin 
each time. It is then turned back to complete 
the circle around the forehead and occiput to 
fix this chin strap. The turns of this dressing 
arc then fastened in place by means of safety 
pins which may be twisted so as to tighten 
the whole into a snug, close-fitting dressing. 
Straps of 1-inch adhesive arc then applied 
about the chin strap, one on each side in front 
of the car and one at the bottom of the loop 
under the chin so as to make a single, neat, 
compact chin strap. Several pins are then ap- 
plied between the circular layers about the fore- 
head and occiput and the clecjier layers over 
the head so as to fix the latter firmly in place. 
This dressing is so seciuc if jn'operly applied 
that even a disturbed patient who is not re- 
sponsible for his actions may have difficulty in 
getting it off (Fig. 3). 

For small lacerations or incisions in the scalp, 
sterile fine-mesh gauze made adherent to the 
skin hy means of flexible collodion makes an 
excellent dressing. The gauze is trimmed to ap- 
propriate size from a sterilized roll of gauze 
roller bandage; usually four to six layers of 
this material are incorporated in the dressing. 
After being trimmed with tlie sterile scissors to 
the size desired, a layer at a time is applied to 
the scalp over the wound and the flexible col- 
lodion is painted on with an applicator around 
the periphery of the gauze, layers being added 
one after another with collodion being applied 
to the edges of each layer to make it adherent. 
This produces a neat dressing which does not 
become involved with hair and will remain 
in place for several days. These dressings are 
useful for wounds on the face, or an exposed 
extremity where not too much is needed to 
cover the wound. An occasional patient is sen- 
sitive to collodion and may develop skin irrita- 
tion from its use. 

Compression dressings on the chest arc im- 
ally applied following radical surgery upon 
the breast. These are used primarily because 
the large skin flaps necessary in this operation 
have to be kept firmly in place against the 
deeper structures in the chest wall if they are 
to adhere without the accumulation of fluid 
beneath them. A similar type of dressing is 
sometimes used by thoracic surgeons after ex- 
tensive procedures on the chest. However, the 
need for skin flaps in this situation is unusual 



Surgical Techniques 


and therefore compression is not so essential 
as it is following radical mastectomy or skin 
grafting to the chest wall. After the usual oc- 
clusive dressing is applied over the wound, a 
large mass of resilient material such as 
fluffed-up gauze or mechanic s waste is mounted 
up in bulky and generous fashion over the 
area for which compression is wished. It is im- 
portant to make certain that any bony promi- 
nences which may be encountered in applying 
the dressing are covered well with padding. 
The dressing is usually started with a 6-mch 
stockinet roller at the waistline and is fixed 
there by tw^o turns of stockinet around the 
waist pinned in place with safety pins. This 
is continued as a simple roller bandage over- 
lapping some 50 per cent on each turn until 
the entire chest is covered, running from the 
back up over the shoulder on the involved side, 
catching the arm in a figure-of-eight spica, and 
coming back after encircling the arm to go 
once more around the chest, thus completing 
the spica bandage. This type of compression 
can then be tightened by means of safety pins, 
as in head dressings, so that firm compression 
can be maintained with comfort to the patient 
and without embarrassment of the respiratory 
function. Such a dressing is often left in place 
for three, four or five days depending upon the 
conditions for which it was applied. A similar 
type of dressing can, of course, be applied with 
elastic bandage materials, but firmer pressure 
and more effective dressings result with the 
use of the stockinet. 

Often it is better not to use dressings about 
the face if the patient is to be kept in a shel- 
tered location such as a hospital room, since 
the application of any dressings to small wounds 
may result in collection of serum or a few 
drops of blood along the suture line. The blood 
or serum may harden and interfere with the 
healing process, particularly if the dressings 
are removed without the greatest of care. This 
is especially true of the face because dressings 
often are taken off quite early to permit removal 
of the suture material in the skin in order to 
prevent scarring due to the sutures themselves. 
Wounds of the face treated without dressings 
are simply wiped off intermittently every few 
minutes for the first hour or two by means of a 
sterile applicator gently rolled over the wound 
'so as to pick up any small amount of serum or 
blood which may have accumulated on the 
wound. After one or two hours these wounds, 
if they have been properly closed, are quite dry 


197 

and scaled so that further contamination bv 
bacteria is unlikely especially if the hands and 
foreign materials are kept away from them. For 
nice!} closed fresh wounds, this is a satisfactory 
procedure. For patients who are to leave the 
hospital or doctor's office, some sort of a dress- 
ing should always be applied. The roost satis- 
factory dressing on the face for small wounds 
is a fine-mesh gauze collodion dressing. For 
those wounds about the face which need com- 
pression dressings, one must be improvised 
from some of the materials which have been 
mentioned, depending upon the location of 
the injury or wound. 

Dressings on the abdomen need not be too 
large, or too thick, since in the average clean, 
elective case they are not expected to absorb 
purulent materials. The}^ are simply used to 
prevent contamination of the w^ound hv bac- 
teria from the air, bedclothes and fingers. Flow- 
e\’er, abdominal dressings should cover the 
wound thoroughly with a safe margin on each 
side. Such dressings are usually fixed by means 
of adhesive tape using the narrowest type prac- 
ticable for the size of dressing used. If some sup- 
port for the abdominal wall is desired with the 
dressing, it is common practice to use 2-inch 
tape. In those cases in which this is not neces- 
sary, 1-inch adhesive tape straps supply enough 
protection with half as much irritation to the 
skin. For repeated dressings upon abdominal 
wounds of smaller size, even 14 -inch adhesive 
straps may be used. It should he emphasized 
that although these straps must go far enough 
past the edge of the gauze to become firmly ad- 
herent to the skin they need not cover large 
expanses of skin which would lead to unneces- 
sary irritation. If on changing dressings such 
adhesive straps are cut at the margin between 
the adherence to the skin and the adherence 
to the gauze, rather than removed each time, 
much less irritation of the skin occurs. The 
new straps can be applied over the old, and, 
in the average elective case, by the time it is 
unnecessary to have further dressings the elas- 
tic adhesive will be so free as to be readily re- 
moved without much pain to the patient. An- 
other means of preventing irritation to the skin 
from adhesive tape is to treat the skin with 
tincture of benzoin before the application of 
the tape. 

Spinal Puncture. Lumbar puncture is a 
procedure which is often done on surgical and 
medical patients. Every house officer should 
try to develop facility and dexterity in this use- 



198 Chapter 8. Basic Principles of Technique in Surgical Care 


ful pr(3cedure. Depending upon the circum- 
stances for which the puncture is done, the pa- 
tient may be put in a sitting posture or may be 
laid on his side. In either position it is important 
to have flexion of the lumbar spine so that the 
spinous processes adjacent to the fourth inter- 
space, the usual site of puncture, he opened as 
much as possible. When the puncture is done 
with the patient lying on his side, this can be 
effected by having him bring his knees up on 
his chest and bend his head down upon his 
chest. With, the patient in this position it is 
important that he be brought well to the edge 
of the bed where the added support of the 
bed frame will maintain the relatively straight 
alignment of the vertebral bodies, as opposed 
to the scoliosis which may occur on a soft bed 
when a patient is allowed to lie on the center 
of it. 

The house officer should never attempt a 
lumbar puncture without previous instructions 
from his attending surgeon and should always 
be supervised in his initial attempt at this pro- 
cedure. Sterile technique should be observed 
in that those present should wear caps and 
masks and those actually doing the procedure 
should wear sterile gloves. The skin should be 
scrubbed over a wide area from the sacrum up 
to the lower thoracic spinous processes and 
from one flank to the other, using soap and 
water. It should be draped with sterile towels. 
The point directly between the tips of the 
third and fourth lumbar spinous processes in 
the midline should he injected with 1 per cent 
procaine until a 1-cm. wheal has been raised. 
Then, using a longer needle and inclining it 
slightly cephalad but maintaining it directly in 
the midline, the injection should be continued 
as the needle is pushed forward to infiltrate the 
interspinous ligament. Usually, this infiltration 
need not be carried deeper than 2 inches. The 
spinal puncture needle is introduced into the 
skin with a short thrust and then slowly pushed 
inward. If it is arrested by striking bone, the 
needle should be pulled out and introduced at 
a less acute or more acute angle as the case 
may require. Although its inclination somewhat 
caudad of perpendicular may be altered to some 
degree, the needle must be maintained exactly 
in the sagittal plane at all times. 

When the needle has finally penetrated the 
spinal canal, this event will be signalled by its 
suddenly ^'falling into’* this space. It is im- 
perative that the needle be guided by both 
hands and that it be always held in such a 


manner that it cannot penetrate too deeply in a 
sudden thrust when the resistance of ligaments 
ahead of it gives way. This, of course, is the 
principle in all procedures involving the intro- 
duction of a needle into a hollow cavity. When 
the needle is in the spinal canal, the stylet is 
gently withdrawn to see whether sjnnal fluid 
will drip from it. If the needle is correctly 
placed, there will be a slow dripping of fluid 
from the hub of the needle. If there is no such 
dripping, the needle may be presumed not to 
lie in the spinal canal and it should be with- 
drawn and reinserted gently and slowly. If 
the needle is advanced too far, it will strike 
nerve roots and the patient will complain of 
sharp pain, usually down the back of the 
thigh. If on withdrawing the stylet the operator 
obtains a flow of blood, the needle should be 
withdrawn and the puncture attempted at a 
different level. Once an adequate flow^ of 
spinal fluid is obtained, the stylet should be in- 
serted in the needle while preparations are 
made to attach a three-way stopcock for de- 
termination of manometric pressure and collec- 
tion of fluid samples. If the patient has been 
subjected to the puncture while he is in the 
sitting position, it is extremely important that a 
minimum amount of fluid be allowed to escape, 
since a sudden lowering of pressure could cause 
a herniation of the cerebellar tonsils through the 
foramen magnum. When increased intracranial 
pressure is suspected, the puncture should not 
he done with the patient sitting. 

After a three-way stopcock has been attached, 
manometric pressures can be determined and 
spinal fluid samples collected. The stylet is then 
replaced in the needle and a small sponge is 
placed on the skin around the needle while 
the needle is quickly withdrawn. The puncture 
site is covered with a small piece of sterile cot- 
ton impregnated with collodion; this makes an 
adequate seal for the wound. 

At the conclusion of the procedure, the pa- 
tient should be instructed not to raise his head 
or to move about vigorously in bed as such ac- 
tivity may induce the so-called "post-spinal 
puncture headaches. Tw^enty-four hours after 
the lumbar puncture, it is safe for the patient 
to do whatever was permitted before the pro- 
cedure. 

Passing the Stomach Tube, Occasionally, 
in the emergency room, it will be necessary 
to empty a patient s stomach. In such instances 
a large Ewald tube is usually employed and it is 
passed through the mouth. It may he necessary 



Surgical Techniques 199 


to pass it on an unconscious patient, for ex- 
ample, in the instance of an individual who 
has taken an overdose of sleeping pills in an 
attempt to commit suicide. The tube should be 
cold and lubricated with ice water or mineral oil; 
it should be arched posteriorly as much as pos- 
sible SC) as to a\T}id an endotracheal passage. Once 
the tube is in the esophagus, it should be passed 
quickl} until it is in the stomach. At this point 
a large aspirating bulb is applied to the end 
of the tube and the contents of the stomach 
quickly aspirated. Should the tube be inad- 
vertently passed into the trachea, usualK a tre- 
mendous gag response will be ex'oked. Should 
there be any question at all whether or not the 
tube is in the trachea, the issue can easily be set- 
tled by feeling the outer end of the tube for 
evidence of expiratory movement of air out of 
the tube. 

In most instances the stomach tube used is a 
"‘'much smaller one, usually a Le\’in tube, which 
is passed through the nose and then through the 
pharynx and down the esophagus into the 
stomach. In many instances it is done as a pre- 
liminary step to some type of surgery on the 
gastrointestinal tract in an effort to eliminate 
postoperative distention and to keep the gastro- 
intestinal tract at rest. Such a tube can be 
passed in the patient’s room. It should be cooled 
ill ice and passed with no lubrication other than 
the ice water which adheres to its surface. 
The patient should be asked whether there is 
any impediment in one nostril or the other so 
that the tube can be put through the more 
natent of .the two nostrils. When the tube 
vyeact 5 the patient’s pharynx it may produce 
soiS^agging. At this point the patient should 
be instructed to swallow hard and if necessary 
even be given some water to drink as this will 
help carry the tube down the esophagus. Pa- 
tients differ in their reactions to this procedure 
and some gag strenuously when the tube is in 
the pharynx. Again, if there is any suspicion 
that the tube has gone into the trachea, the 
outer end of the tube should be held next to 
the cheek or back of the hand to see whether 
expired air is issuing from it. If such is not the 
case and the gagging seems disproportionate to 
what might be expected, the pharynx should he 
examined by means of a flashlight to see 
whether or not the tube is curling up in it. If 
it has curled up in the pharynx the tube should 
be withdrawn through the nose until the tip 
can just be seen above the middle of the soft 
palate and then the swallowing should be 


begun again as the tube is slowly passed. Hav- 
ing the patient pant, or breathe rapidly through 
the mouth, may facilitate the process. The posi- 
tion of the tube within the stomach can be 
confirmed by aspirating gastric contents. \Try 
rarely will a tube, proper!) placed within the 
stomach, fail to vieM some gastric contents. 
fdowe\'er, if it seems that the tube is in the 
stomach and yet nothing can be aspirated, the 
tube should be gently irrigated with 50 cc. of 
water, most of which should return on 
aspiration. 

When a tube of the Miller- Abbott t\pc is 
being employed in an effort to apply suction 
at some point beyond the pylorus, it is im- 
portant that the tube have appropriate mark- 
ings on it so that the amount which has been 
passed into the stomach can be easily de- 
termined by glancing at the part which re- 
mains outside. When extreme difficulty is ex- 
perienced in passing a tube, it may he neces- 
sary to spray the pharynx with a 2 per cent 
solution of cocaine, as is done before bronchos- 
copy. 

Thoracentesis. This procedure is fre- 
quently employed. It is usually performed for 
the removal of fluid from a pleural effusion, but 
often for diagnostic aspiration of minor ef- 
fusions which are thought to have resulted from 
neoplasms of the lung. Unless circumstances 
dictate otherwise, puncture is usually made in 
the posterior axillary line at the lowest level in 
which it is expected that fluid can be encoun- 
tered. This level is determined by percussion 
and x-ray findings. The puncture of the pleural 
cavity is usually made with the patient in the 
sitting position, although circumstances may 
require that the patient be left on his side. 
Many surgeons feel that the patient should 
be given ^50 grain of atropine at least one-half 
hour before the procedure to eliminate any 
possibility of a noxious reflex mediated by the 
vagus nerves. The procedure should be done 
under conditions of sterile technique with the 
house officer capped, masked, and wearing 
sterile glo\^es. The skin may be scrubbed widely 
with soap and water, ox iodine and alcohol, or 
another acceptable antiseptic used. 

The field is draped with sterile towels. A 
I per cent solution of procaine is injected into 
the skin to produce a wheal through which the 
deeper tissues are infiltrated with another 5 to 
10 cc. of the same anesthetic. The thoracentesis 
needle is slowly introduced through this in- 
filtrated area just beneath the edge of the rib 



200 


Chapter 5 . Basic Principles of Techniques in Surgical Care 


until the feeling o£ resistance suddenly disap- 
pears and the needle sinks in rather quickly. 
The house officer should be prepared for such 
an event and should be holding the leedle 
so that it cannot suddenly fall into the p eural 
space to any depth. The pleural fluid is usually 
withdrawn by means of a three-way stopcock 
which prevents the influx of air into the 
pleural cavity. When the thoracentesis has 
been peifermed for relief of pneumothorax, 
it is particularly important that this precaution 
be observed. It is also important that a large 
pneumothorax not be aspirated too quickly, as 
a sudden shift in the mediastinal contents could 
produce cardiac distress. 

When the aspiration has been completed, 
the needle is quickly withdrawn through sterile 
gauze held close about its point of entrance 
through the skin. The area is then sealed with a 
small piece of cotton impregnated with col- 
lodion. 

OBSERVING THE AMENITIES 

An)' member of the house staff who enters 
a patient s room, or comes to the bedside of a 
patient in a ward, should introduce himself 
and explain his relationship to the attending 
physician, as for example: “I am Dr. Smith, 
Dr. Jones’ associate” or, “I am Dr. O’Brien, a 
resident on Dr. Jones’ service.” There can never 
be any excuse for omission of this simple act 
of courtesy when an individual member of the 
house staff comes into contact with a patient. 
The attending surgeon will usually make such 
introductions on the first visit he makes to the 
patient in company with his intern and/or resi- 
dent, but he knows that these men usually 
have seen the patient in the hospital before he 
has, so that introductions are not necessary. 

Before the intern or resident under^f’ke.*! ■ 
procedure with the patient, even be it so sim- 
ple a thing as taking his history, he should tel^ 
the patient simply but in a clear manner just 
exactly what he plans to do. This may seem 
very fundamental but far too many patients are 
examined, questioned, subjected to rectal exam- 
ination, venipuncture and sometimes even 
spinal puncture without any preliminary ex- 
planation of what is about to take place. This 
is discourteous, and leads to misunderstanding, 
fear and resentment. It is particularly important 
in dealing with children that simple, yet ade- 
quate explanations he given in advance of any 
surgical procedures, even though it he so 
minor as the drawing of blood or the changing 


of a dressing. Children tolerate pain and un- 
pleasantness surprisingly well if they have 
been warned about it in advance, and if they 
do not feel they have been deceived by those 
who are caring for them. 

Of course, the young surgeon’s concern 
for propriety in relationships with the patient 
is not limited to the patient’s room. When the 
patient is being taken to the operating room, 
it is imperative that the trip be made as smooth 
as possible. The cart should be handled gently 
and not bumped in the course of moving the 
patient from his room to another floor for sur- 
gical procedures. In the course of such a trip 
conversation between the house officer and 
the patient, if there is to be any, should relate 
to innocuous subjects. If there is any discus- 
sion of the forthcoming procedure, it should be 
brief and reassuring. The attending surgeon 
will, of course, have prepared the patient in 
advance for what is to occur in the operating 
room and, therefore, the house officer should do 
nothing to disturb the patient’s serenity, pre- 
sumably already achieved by preoperative 
medication. 

In the operating room and in the corridors of 
the operating suite, it is essential that an air of 
quiet prevail. Laughing, loud talking, and even 
persistent whispering are incompatible with 
the competence and business-like performance 
which the patient expects in a room where his 
life may well be in jeopardy. 

Even in conditions of extreme quiet, how- 
ever, a prolonged wait may be very disturbing 
to the patient’s peace of mind, so he should 
not be brought to the operating room any 
earlier than is necessary for expeditious han- 
dling. When he has reached the operating 
floor, he should not he left unattended in the 
corridor for any period of time but should be 
transferred immediately to the room where his 
operation is to be performed. 

In the operating room the attending surgeon 
is responsible for whatever goes on. This re- 
sponsibility is a moral and ethical one, as well 
as a medicolegal one. In the last respect it is 
only partially shared by the anesthesiologist 
and by the hospital through its salaried em- 
plcyees such as nurses, orderlies and other at- 
tendants, The surgeon must take full charge 
of all that goes on in the operating room and 
is completely responsible for whatever happens 
to the patient. Therefore, members of the house 
staff should do whatever tasks have been as- 
signed to them and wait quietly for the opera- 



9 


The Principles of the Surgical Care 
to the Soft Tissues 

By HARVEY S. ALLEN, M.D. 

Harvey Stuart Allen, whose untimely death occurred just after he had completed 
this chapter and his contribution on Burns, was a Professor of Surgery at Northwestern 
University. He was a Montanan by birth and received his education at Washington 
State University and Northwestern University. Dr. Allen had long shown cm interest 
in the immediate care of injuries and in the treatment of burns. His methods have 
become recognized universally. The meticulous and thorough efforts characteristic of 
his surgical teachings to create a closed, clean wound out of an open, dirty, destructive 
injury were repaid multiply by shortening the convalescent period, restoring function 
more completely, and decreasing economic loss for the patient. 


E\’ery form of trauma to the "body produces 
some type of injury and wounding to the soft 
tissues. These injuries inflict various types and 
degrees of wounds and, frequently, there are 
combinations of types created in each wound. 

The soft tissue wounds are classified in vari- 
ous ways and, at times in surgical parlance, dif- 
ferent terms may be applied to the same wound. 
In general, all wounds are either closed or 
open. The closed wound does not produce 
an obvious break in the skin at the time of in- 
jury but a break may later occur and become 
apparent. A conhision or a sprain is a typical 
example. The open injuries may vary from 
sharp wounds, as lacerations, or penetrating 
injuries, to perforating wounds, crushing in- 
juries, abrasions and avulsions. War injuries 
caused by high-velocity shell fragments pro- 
duce wounds which are combinations of all 
types. 

A contusion results from a blow to the skin 
and soft parts, creating a variable amount of 
damage of the tissues. Hemorrhage and edema 
occur within the skin and soft parts but the 
skin IS intact initially. There can he deeper 
involvement of bone or soft organs under the 

Page 


site of injury. The swelling resulting from cel- 
lular breakdown, edema, and hemorrhage may 
become excessive and occlude the blood vessels 
of the soft tissues, resulting in death of the 
overlying parts. The soft tissue covering is not 
in a healthy condition and can become infected. 
The wounded area should be cleansed, care- 
fully protected by compression dressing and 
splintage until healing is assured, The under- 
lying hematoma may later require aspiration or 
removal. 

A sprain is a tearing of ligaments, tendons or 
muscular tissues, leaving hemorrhage and 
edema in the area. The loss of function result- 
ing depends on the laceration and the degree 
of rupmre of the fibers. The swelling may be- 
come injurious to the overlying tissues, and 
therefore rest, elevation and compression should 
be utilized until healing has occurred. 

The open injuries create a break into or 
actual l^s, to a varying degree, of the covering 
tissues. The skin has lost its continuity, and in- 
fection from the wounding agent or contamina- 
tion may occur. 

A laceratwn is usually created by a sharp 
agent, leaving a clean incised wound. The 
202 





9 


The Principles of the Surgical Care 
to the Soft Tissues 

By HARVEY S. ALLEN, M.D. 

Harvey Stuart Allen, whose untimely death occurred just after he had completed 
this chapter and his contribution on Burns, was a Professor of Surgery at Northwestern 
University. He was a Montanan by birth and received his education at Washington 
State University and Northwestern University. Dr, Allen had long shown an interest 
in the immediate care of injuries and in the treatment of burns. His methods have 
become recognized universally. The meticulous and thorough efforts characteristic of 
his surgical teachings to create a closed, clean wound out of an open, dirty, destructive 
injury were repaid imdtlply by shortening the convalescent period, restoring function 
more completely, and decreasing economic loss for the patient. 


E\'ery form of trauma to the body produces 
some type of injury and w^ounding to the soft 
tissues. These injuries inflict various types and 
degrees of wounds and, frequently, there are 
combinations of types created in each wound. 

The soft tissue wounds are classified in vari- 
ous ways and, at times in surgical parlance, dif- 
ferent terms may be applied to the same wound. 
In general, all wounds are either closed or 
open. The closed wound does not produce 
an obvious break in the skin at the time of in- 
jury but a break may later occur and become 
apparent. A contusion or a sprain is a typical 
example. The open injuries may vary from 
wounds, as lacerations, or penetrating 
injuries, to perforating wounds, crushing in- 
juries, abrasions and avulsions. War injuries 
caused by high-velocity shell fragments pro- 
duce wounds which are combinations of all 
types. 

A contusion results from a blow to the skin 
and soft parts, creating a variable amount of 
damage of the tissues. Hemorrhage and edema 
occur within the skin and soft parts but the 
skin is intact initially. There can he deeper 
involvement of bone or soft organs under the 


site of injury. The swelling resulting from cel- 
lular breakdown, edema, and hemorrhage may 
become excessive and occlude the blood vessels 
of the soft tissues, resulting in death of the 
overlying parts. The soft tissue covering is not 
in a healthy condition and can become infected. 
The wounded area should be cleansed, care- 
fully protected by compression dressing and 
splintage until healing is assured. The under- 
lying hematoma may later require aspiration or 
removal. 

A sprain is a tearing of ligaments, tendons or 
muscular tissues, leaving hemorrhage and 
edema in the area. The loss of function result- 
ing depends on the laceration and the degree 
of rupture of the fibers. The swelling may be- 
come injurious to the overlying tissues, and 
therefore rest, elevation and compression should 
be utilized until healing has occurred. 

The open injuries create a break into or 
actual loss, to a varying degree, of the covering 
tissues. The skin has lost its continuity, and in- 
fection from the wounding agent or contamina- 
tion may occur. 

A laceration is usually created by a sharp 
agent, leaving a clean incised wound. The 


Page 202 



203 


The Principles of the Surgical Care to the Soft Tissues 


damage from such a wound is confined only to 
the structures divided, and the surrounding 
areas are not compromised by the injury. 

A penetrating iwund is created by an agent 
such as a missile or instrument, and the wound 
of entrance may be small and the tract narrow 
and deep. The organs and tissue involved de- 
pend on the direction of the wuunding agent 
and the force. When a through-and-through 
wound is ^produced, it is known as a perforating 
ivotind; in these, the wound of entrance is 
small while the w’ound of exit is larger and 
more jagged. The high-velocity missiles em- 
ployed in war produce such w'ounds of entry 
and exit, but the central portion of the wmund 
tract has been seriously in\"olved by the ex- 
panding force of the shell fragment. There 
results a large central core of tissue which is 
torn and contused, and in which necrosis 
occurs. 

The crushing injuries are a serious combina- 
tion of a local wound of the soft parts, plus 
tearing and rupturing of the involved tissues. 

The least degree of such an injury is an ab- 
rasion, which is a wound created by a scraping 
action parallel to the skin surface. The epithe- 
lium is partially denuded. The skin has lost 
the ability to combat infection. Soon after the 
injury, serum and blood ooze onto the surface 
and this eventually dries, forming a crust which 
should not be disturbed unless the area be- 
comes infected. Healing of a clean abrasion 
occurs by epithelial outgrowth from the edges 
and also from the residual skin elements, such 
as the sweat glands and hair follicles. 

Avtilsing wounds are created by blunt or 
jagged agents; their edges are irregular and the 
skin and subcutaneous tissues are undermined 
and torn. The flap of crushed tissue is jeopard- 
ized because of the associated injury to the 
blood vessels of the part. The structures be- 
neath have also been involved to a variable 
degree. Necrosis of the tissues from the injury 
itself plus the additional factors of edema and 
hemorrhage tTus creates a wound which carries 
a great potential of infection. 

Effect of Wounds. Locally, each wound 
results in injury of varying degree of the under- 
lying tissues. There is immediate hemorrhage 
from the torn, lacerated or crushed blood ves- 
sels, from, into and about the wound. The pres- 
ence of blood in the intercellular spaces ex- 
cites an outpouring of serum, as if to dilute this 
extravasated blood. The intercellular blood and 
serum account for the swelling about the site of 


injury. This swelling can become excessive, 
and, if confined within nonresilient fascial 
spaces, can by pressure actually interfere with 
the vascularity of the tissues, creating a further 
degree of necrosis. The trauma to the tissues 
can also produce bursting and death of the 
cells. Hemorrhage into the area can cause death 
of the tissues immediately, or, if not excessive 
and if the hlood is allowed to remain, will 
leave residual scarring. Accumulations of blood 
within the wound must be avoided and pre- 
vented as far as possible. 

The local wound of the soft parts is in effect 
a break in continuin' of the tissue or a fracture 
of the tissue, and therefore the affected area 
should always be provided with rest and im- 
mobilization. 

The wounding agent may involve deeper 
vital structures, such as vessels, nerves, tendons 
and various organs and bones. Because of this, 
the surgeon must be aware of the anatomy in- 
volved, and test appropriately for function of 
the potentially involved structures. 

Trauma of the soft parts may be of sufficient 
degree to create shock from blood loss or by 
compromising some \dtal organ. The bleeding 
need not be visible and the blood may not be 
pouring out from the wound. It can be entering 
the wounded tissues and a large amount of it 
may